A home health nurse is providing education to a client discharged with a tracheostomy. Which statement by the client demonstrates teaching has been effective?

“My spouse should always take care of my tracheostomy. I should not do it myself.”.

“I am the only one who needs to know how to suction my tracheostomy at home.”.

“I can use my saline for longer than 24 hours if I boil it.”.

“I can use clean instead of sterile technique to suction my tracheostomy.”.

Answer and Explanation

The Correct Answer is D

“I can use clean instead of sterile technique to suction my tracheostomy.” This statement demonstrates that the client understands how to care for their tracheostomy at home. According to the American Thoracic Society, clean technique can be used for suctioning at home, as long as the equipment is cleaned and stored properly.

Choice A is wrong because the client should be able to take care of their own tracheostomy as much as possible, with the help of a caregiver if needed. This promotes independence and self-care.

Choice B is wrong because the client should not be the only one who knows how to suction their tracheostomy at home. They should have at least one backup person who can assist them in case of an emergency or if they are unable to do it themselves.

Choice C is wrong because the client should not use saline for longer than 24 hours, even if they boil it.

Saline can become contaminated with bacteria and cause infection. The client should use fresh saline every time they suction their tracheostomy.

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Correct Answer is B

Explanation

“My medication will be given at the scheduled times to best manage my pain.” This statement demonstrates understanding of the pain management plan because it shows that the client knows the importance of preventing pain from becoming severe by taking medication regularly. Scheduled administration of analgesics is more effective than administering them on demand.

Choice A is wrong because it implies that the client will wait until the pain is severe before asking for medication, which can make it harder to control.

Choice C is wrong because it suggests that the client expects to receive inadequate pain relief due to their history of opioid abuse, which is not ethical or evidence-based.

Choice D is wrong because it indicates that the client believes they will be denied any narcotics for pain, which is also not ethical or

evidence-based. Clients with a history of opioid abuse can still receive opioids for acute pain, but they may need higher doses or more frequent administration to achieve adequate analgesia.

Normal ranges for vital signs are as follows: respiratory rate 12-20 breaths per minute, heart rate 60-100 beats per minute, blood pressure 120/80 mmHg, temperature 36.5-37.5°C (97.7- 99.5°F).

A. I will avoid excessive amounts of cheese and caffeine. B. My spouse will just have to put up with any new irritability. C. I will change positions slowly, as dizziness may occur. D. My spouse will check my blood pressure if I experience a headache.

Correct Answer is B

Explanation

My spouse will just have to put up with any new irritability. This statement indicates that the client requires further educational reinforcement about the medication because phenelzine is an antidepressant that should improve the mood and reduce irritability. The client may also need to be assessed for possible adverse effects of phenelzine, such as agitation, insomnia, or hypomania.

Choice A is wrong because it is a correct statement. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with foods that contain tyramine, such as cheese and caffeine, and cause a hypertensive crisis.

The client should avoid excessive amounts of these foods while taking phenelzine.

Choice C is wrong because it is also a correct statement. Phenelzine can cause orthostatic hypotension, which is a drop in blood pressure when changing positions.

The client should change positions slowly, as dizziness may occur.

Choice D is wrong because it is partially correct. Phenelzine can cause headaches, which may be a sign of a hypertensive crisis.

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A home health nurse is providing education to a client discharged with a tracheostomy. Which statement by the client demonstrates teaching has been effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has developed a pain management plan for a client who has a history of opioid drug abuse. Which of the following statements by the client demonstrates understanding of the pain management plan?

Correct Answer is B

Explanation

A client has been recently started on phenelzine, a monoamine oxidase inhibitor (MAOI) for depression. Which statement indicates that the client requires further educational reinforcement about the medication?

Correct Answer is B

Explanation

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