The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat?
Inflate the cuff
Rationale: If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inf...
the nurse is preparing to assist a client with a cuffed tracheostomy tube to eat what intervention is the priority before the client is permitted to drink or eat inflate th
Written for
Chamberlain College Of Nursing
2021 HESI MED SURG
All documents for this subject (31)
Seller
Follow
doctorsolutions65
Reviews received
Content preview
lOMoARcPSD|3920845
HESI MED-SURG STUDY GUIDE
The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat.
What intervention is the priority before the client is permitted to drink or eat?
Inflate the cuff
Rationale: If a client with a tracheostomy is allowed to eat and the tracheostomy
has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids.
The cuff would not be deflated because of the risk of aspiration.
The nurse has implemented a bowel maintenance program for an unconscious
client. The nurse would evaluate the plan as best meeting the needs of the client
if which method was successful in stimulating a bowel movement? Glycerin
suppository
Rationale: The least amount of invasiveness needed to produce a bowel
movement is best. Use of glycerin suppositories is the least invasive
method and usually stimulates bowel evacuation within a half-hour.
A client is readmitted to the hospital with dehydration after surgery for creation of
an ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor
skin turgor, and has concentrated urine. The nurse interprets the client's clinical
picture as correlating most closely with recent intake of which medication, which
is contraindicated for the ileostomy client? Biscodyl
Rationale: The client with an ileostomy is prone to dehydration because of
the location of the ostomy in the gastrointestinal tract and should not take
laxatives.
The client is complaining of skin irritation from the edges of a cast applied the
previous day. Which action should the nurse take? The nurse petals the edges of
the cast with tape Rationale: minimize skin irritation.
The nurse is taking a health history for a client with hyperparathyroidism. Which
question would elicit information about this client's condition? "Are you
experiencing pain in your joints?"
Rationale: Hyperparathyroidism is associated with over secretion of parathyroid hormone
(PTH), which causes excessive osteoblast growth and activity within the bones. When bone
reabsorption is increased, calcium is released from the bones into the blood, causing
hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone
and joint pain
, lOMoARcPSD|3920845
A client with type 2 diabetes mellitus has a blood glucose level greater than 600
mg/dL (34.3 mmol/L) and is complaining of polydipsia, polyuria, weight loss, and
weakness. The nurse reviews the health care provider's documentation and
expects to note which diagnosis? Hyperosmolar hyperglycemic syndrome (HHS)
Rationale: HHS is seen primarily in clients with type 2 diabetes mellitus, who
experience a relative deficiency of insulin. The onset of signs and symptoms
may be gradual.
Manifestations may include polyuria, polydipsia, dehydration, mental status
alterations, weight loss, and weakness.
The nurse is developing a plan of care for a client who will be admitted to the
hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The
nurse develops the plan, expecting that the health care provider (HCP) will most
likely prescribe which option? ---Maintain activity level as prescribed.
Rationale: Standard management for the client with DVT includes maintaining the
activity level as prescribed by the health care provider; limb elevation; relief of
discomfort with warm, moist heat; and analgesics as needed. Recent research is
showing that ambulation, as previously thought, does not cause pulmonary
embolism and does not cause the existing DVT to worsen. Therefore, the nurse
should maintain the prescribed activity level, which could be bed rest or ambulation.
Opioid analgesics are not required to relieve pain, and pain normally is relieved with
acetaminophen.re provider (HCP) will most likely prescribe which option? Maintain
activity level as prescribed.
A client has had surgery to repair a fractured left hip. When repositioning the
client from side to side in the bed, what should the nurse plan to use as the most
important item for this maneuver?------Abductor splint
Rationale: After surgery to repair a fractured hip, an abductor splint is used
to maintain the affected extremity in good alignment. A bed pillow and an
overhead trapeze also are used, but neither is the priority item to be used in
repositioning the client from side to side.
The nurse is preparing to care for a client who had a supratentorial
craniotomy. The nurse should plan to place the client in which position?
Semi Fowler's
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller doctorsolutions65. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $14.49. You're not tied to anything after your purchase.
