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.”.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because diminished breath sounds indicate poor oxygenation and ventilation, which can lead to respiratory failure and hypoxia. The healthcare provider should be notified immediately to assess the client and provide appropriate interventions.
Choice A is wrong because joint pain is a common side effect of some arthritis medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). It does not require immediate attention unless it is severe or accompanied by other symptoms, such as swelling, redness, or fever.
Choice B is wrong because decreased appetite and difficulty sleeping are normal responses to grief and loss. They do not indicate a medical emergency, but rather a need for emotional support and counseling.
Choice C is wrong because a weight loss of two pounds in a client admitted with congestive heart failure is a positive sign that indicates fluid removal and improved cardiac function. It does not require immediate reporting, but rather ongoing monitoring and evaluation.
Normal ranges for vital signs are as follows :
- Blood pressure: 90/60 mm Hg to 120/80 mm Hg
- Breathing: 12 to 18 breaths per minute
- Pulse: 60 to 100 beats per minute
- Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)
Correct Answer is C
Explanation
The first observation the nurse should perform for a client who is receiving from the post anesthesia unit after a colon resection is to assess the patency of the airway and respiratory function.
This is because the airway is the most vital for the survival of the client and any compromise can lead to hypoxia and death.
The nurse should then take vital signs, check the wound dressing, and assess the foley catheter drainage.
Choice A is wrong because the client’s wound dressing is not as important as the airway and can be checked later.
Choice B is wrong because the client’s level of consciousness may be affected by the anesthesia and is not a priority over the airway.
Choice D is wrong because the client’s foley catheter drainage is not a critical observation and can be monitored later.
Normal ranges for respiratory rate are 12 to 20 breaths per minute for adults, oxygen saturation is 95% to 100%, and blood pressure is 120/80 mmHg for healthy individuals.
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