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 C

Explanation

This is because restraints should only be used as a last resort when other alternatives have failed to ensure the patient’s safety and when there is a valid order from the primary healthcare provider.

Assessing the need for restraints placement involves evaluating the patient’s condition, behavior, risk factors, and potential benefits and harms of using restraints.

Choice A is wrong because visual inspection of skin for placement is done after applying restraints, not before.

This is to check for any signs of injury, irritation, or circulation impairment caused by the restraints.

Choice B is wrong because positioning for proper body alignment is done during and after applying restraints, not before.

This is to prevent complications such as pressure ulcers, contractures, or nerve damage due to improper positioning.

Choice D is wrong because reviewing facility policy before usage is not a nursing intervention, but a legal and ethical requirement.

Nurses should be familiar with the facility policy and guidelines regarding the use of restraints and follow them accordingly.

However, this does not replace the need for individualized assessment and evaluation of each patient’s situation.

A. I can stop taking the medication once my hallucinations stop. B. I will discuss any use of alcohol with my health care provider before using it with the medication. C. I should start seeing improvement of my symptoms within a few days. D. I will avoid direct Sun exposure and use sunscreen if I have to be outdoors.

Correct Answer is A

Explanation

This statement suggests that the client needs further teaching because haloperidol is a medication that needs to be taken regularly and consistently to prevent relapse of symptoms related to schizophrenia. Stopping the medication abruptly can cause withdrawal effects and worsen the condition.

Choice B is wrong because it shows that the client understands the potential interaction between alcohol and haloperidol, which can increase the risk of sedation, drowsiness, and low blood pressure.

Choice C is wrong because it indicates that the client has realistic expectations about the onset of action of haloperidol, which can take several days or weeks to show improvement of symptoms.

Choice D is wrong because it demonstrates that the client is aware of the possible side effect of photosensitivity caused by haloperidol, which can make the skin more prone to sunburn and damage.

Haloperidol is an antipsychotic drug that works by blocking dopamine receptors in the brain. It is used to treat symptoms such as hallucinations, delusions, paranoia, and disorganized thinking in schizophrenia and other psychotic disorders. The normal dosage range for haloperidol is 0.5 to 20 mg per day, depending on the severity of the condition and the response to treatment. Some of the common side effects of haloperidol include extrapyramidal symptoms (EPS), such as muscle stiffness, tremors, restlessness, and abnormal movements; neuroleptic malignant syndrome (NMS), which is a rare but serious condition characterized by fever, muscle rigidity, altered mental status, and autonomic instability; and tardive dyskinesia (TD), which is a chronic movement disorder that involves involuntary movements of the tongue, lips, face, and limbs. Haloperidol can also cause weight gain, dry mouth, blurred vision, constipation, dizziness, insomnia, and sexual dysfunction.

Haloperidol should be used with caution in patients with cardiovascular disease, liver disease, seizure disorder, diabetes mellitus, thyroid dysfunction

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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

Which nursing intervention should be performed before applying client restraints?

Correct Answer is C

Explanation

A client is prescribed haloperidol for the treatment of symptoms related to schizophrenia. What client statement suggests that the client needs further teaching?

Correct Answer is A

Explanation

A nurse should include which rationale when instructing a client to avoid sitting with knees crossed?

Which assessment finding is suggestive of an adaptive coping strategy in an individual?

For a client who is crying and seems agitated after major abdominal surgery, which action should a nurse take to establish a nursing diagnosis of pain related to an abdominal incision?

A male client weighing 175 pounds is to receive an intramuscular injection into his deltoid of two milliliters (2 mL) of a viscous fluid. Which needle size should a nurse use?

The client’s 24-hour urine output is 750 mL and an amber color, oral intake is 1700 mL, and the weight has increased 3 kilograms in 2 days. The client is irritable and states “I have a headache.” Which laboratory value most correlates with these signs and symptoms?

A nurse is developing a plan of care for a client diagnosed with constipation. Which nursing interventions should be included in planning? (Select all that apply).

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?

A client with severe bronchial pneumonia has been receiving oxygen, respiratory treatments, antibiotics, and intravenous fluids. Which arterial blood gas result would indicate that the treatment has been effective?