A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?
A. Withdraw the catheter if the client begins coughing
B. Apply suction for 10 seconds
C. Advance the cath...
a nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy which of the following actions should the nurse take when s
ATI Comprehensive Online Practice 2019 A
A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?
A. Withdraw the catheter if the client begins coughing
B. Apply suction for 10 seconds
C. Advance the catheter 2 cm (0.8 in) after resistance is met
D. Use medical asepsis when performing the procedure - Answer- CORRECT: Apply suction for 10 seconds
Rationale: The nurse should apply suction for only 5 to 15 seconds to minimize oxygen loss.
Rationale A: Suctioning can initiate the cough reflex as it opens the airway further and allows for more effective removal of mucus.
Rationale C: Once resistance is met, the nurse should withdraw the catheter 1 to 2 cm (0.4 in to 0.8 in) to prevent damaging bronchial tissues.
Rationale D: The nurse should use surgical asepsis when suctioning a newly created tracheostomy to reduce the risk for infection.
A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include?
A. "This type of nutrition is more effective than eating by mouth.:
B. "You will receive fingersticks for blood glucose testing."
C. "TPN is a way to provide vitamins and minerals without increased calories."
D. "Taking TPN can increase the risk of developing a latex allergy." - Answer- ANSWER: "You will receive fingersticks for blood glucose testing."
Rationale: A client who is receiving TPN is at risk for hyperglycemia due to the dextrose in the TPN solution. Therefore, the client will require blood glucose monitoring.
Rationale A: The client should receive oral or enteral nutrition whenever possible because it enhances the immune system and maintains intestinal motility. However, the client should receive TPN when nutritional needs are greater than oral or enteral nutrition can provide, such as in a client who has burn injuries.
Rationale C: TPN provides calories to clients who are unable to eat or who do not have a functioning gastrointestinal tract. A client who has a burn injury is in a hypermetabolic state and requires additional calories, carbohydrates, proteins, and fats.
Rationale D: The nurse should check the client for an egg allergy, because this can result in an intolerance of the lipid solution and many lipids are composed of egg phospholipids. A nurse is initiating discharge planning for a client who had a stroke and is experiencing
right-sided weakness. Which of the following actions should the nurse take first?
A. Ask a social worker to identify the client's insurance eligibility for rehabilitation services.
B. Request a referral for the client to receive physical therapy.
C. Arrange for the delivery of prescribed medications to the client's home.
D. Provide the client with a list of community resources. - Answer- ANSWER: Request a
referral for the client to receive physical therapy.
Rationale: The greatest risk to this client is injury from falls. Therefore, the first action the nurse should take is to request a referral for physical therapy.
Rationale A: The nurse should ask a social worker to determine the client's insurance eligibility for rehabilitation services to enable continuity of care closer to the time of discharge. However, there is another action the nurse should take first.
Rationale C: The nurse should arrange for the delivery of prescribed medications to the client's home to ensure the client has the medications available. However, there is another action the nurse should take first.
Rationale D: The nurse should provide the client with a list of community resources once the health care team establishes which services will be used for rehabilitation. However, there is another action the nurse should take first.
A nurse is planning care for a client who has a deficit with cranial nerve (CN) II. Which of the following actions should the nurse plan to take?
A. Keep the client resting in bed.
B. Ask the client to restate directions.
C. Clear objects from the client's walking area.
D. Evaluate the client's ability to swallow. - Answer- ANSWER: Clear objects form the client's walking area.
Rationale: The nurse should plan to clear objects from the client's walking area because
CN II is the optic nerve and a deficit can result in visual impairment which can lead to falls.
Rationale A: A client who has a CN II deficit does not require bed rest but should have assistance when out of bed.
Rationale B: The nurse should plan to ask clients to restate directions if they have a CN VIII deficit because CN VIII affects hearing.
Rationale D: The nurse should plan to evaluate the swallowing ability of clients who have a CN IX deficit because it can impair swallowing.
A nurse is providing teaching about improving nutrition for a client who has multiple sclerosis. Which of the following instructions should the nurse include? SATA A. "A speech pathologist will be performing a swallowing study for you."
B. "You should rest before eating a meal."
C. "You should restrict foods that are high in vitamin D."
D. "Reduce your intake of dietary fiber."
E. "Thicken your beverages before drinking." - Answer- ANSWER: A, B, E
Rationale A: The nurse should instruct the client that a swallowing study will be performed to determine the client's risk for aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis.
Rationale B: The nurse should encourage the client to rest before each meal. Clients who have multiple sclerosis often report weakness and are easily fatigued.
Rationale C: The nurse should instruct the client to maintain adequate vitamin D levels, because vitamin D deficiency is a risk factor for multiple sclerosis.
Rationale D: The nurse should instruct the client to increase dietary fiber and fluids to decrease the risk of constipation, which is a manifestation of multiple sclerosis.
Rationale E: The nurse should instruct the client that liquids should be thickened to reduce the risk of aspiration due to difficulty swallowing, which is a manifestation of multiple sclerosis.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the following actions should the nurse take while waiting for a new infusion pump?
A, Administer the TPN solution at the same rate using manual drip tubing.
B. Offer the client oral fluids in place of TPN solution
C. Infuse 0.9% sodium chloride solution using manual drip tubing at 30 mL/hr
D. Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr - Answer- ANSWER: Provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr
Rationale: The nurse should use an infusion pump when administering TPN solution to ensure accurate dosage and should taper the infusion rate before discontinuing the solution to prevent hypoglycemia. If the nurse is unable to continue the TPN infusion by infusion pump, the nurse should use manual drip tubing to infuse dextrose 10% in water
at the same rate as the TPN solution.
Rationale A: The nurse should administer the TPN solution using an infusion pump to deliver it at a controlled rate and reduce the risk of hyperglycemia.
Rationale B: The nurse should continue to provide fluids by IV infusion to a client who has been receiving a continuous TPN infusion to prevent rebound hypoglycemia.
Rationale C: The nurse should infuse an IV solution that will maintain adequate blood glucose levels to reduce the risk for hypoglycemia.
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