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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
To explain why, we need to use the formula for calculating the drip rate in drops per minute (dpm):
Volume of IV fluid (mL) x Drop Factor (drops/mL) / Time to run (h) x 60 (min/h) = Drip Rate (dpm)
In this question, the volume of IV fluid is one liter, which is equivalent to 1000 mL. The drop factor is 15 drops per mL, as given by the tubing.
The time to run is six hours, as ordered by the physician. Plugging these values into the formula, we get:
1000 mL x 15 drops/mL / 6 h x 60 min/h = 84 dpm
Therefore, the nurse should regulate the infusion to deliver 84 drops per minute.
Choice A is wrong because it gives a drip rate of 42 drops per minute, which is half of the correct answer.
This would result in delivering only 500 mL of normal saline in six hours, instead of one liter.
Choice C is wrong because it gives a drip rate of 100 drops per minute, which is more than the correct answer.
This would result in delivering 1.43 liters of normal saline in six hours, instead of one liter.
Choice D is wrong because it gives a drip rate of 166 drops per minute, which is almost double the correct answer.
This would result in delivering 1.99 liters of normal saline in six hours, instead of one liter.
Normal saline is a solution of 0.9% sodium chloride in water, which has the same osmolarity as blood plasma.
It is used to treat dehydration, shock, blood loss, and other conditions that require fluid replacement.
The normal range of sodium in blood is 135-145 mEq/L.
Correct Answer is B
Explanation
Limiting fluid intake can lead to dehydration and concentrated urine, which can irritate the bladder and increase the risk of infection. Older adults should drink about 2 liters of fluid per day unless they have a medical condition that requires fluid restriction.
Choice A is correct because taking diuretics in the morning can reduce nocturia and improve sleep quality.
Choice C is correct because using a commode next to the bed can prevent falls and injuries that may occur when trying to reach the bathroom in a hurry.
Choice D is correct because using a commode in the room can preserve dignity and comfort, and reduce skin breakdown and odor that may result from wearing adult briefs.
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