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

Just prior to the next scheduled dose. A trough level is the lowest concentration of a drug in the blood, and it is measured just before the next dose is due to be administered.

This helps to ensure that the drug level does not fall below the therapeutic range or rise above the toxic range.

Choice A is wrong because every morning at 08:00 AM (0800) is not a consistent time interval for a drug that is administered every twenty-four hours.

The trough level should be measured at the same time before each dose.

Choice B is wrong because halfway between next scheduled dose is not a trough level, but a midpoint level.

This does not reflect the lowest concentration of the drug in the blood.

Choice D is wrong because two hours after a scheduled dose is not a trough level, but a peak level. This is the highest concentration of the drug in the blood, and it is measured after the drug has been absorbed and distributed. Peak levels are no longer routinely recommended for vancomycin.

A. “As soon as I feel any pain, I will ask the nurse to administer my medication.” B. “My medication will be given at the scheduled times to best manage my pain.” C. “The nurse will administer less pain medication than ordered due to my drug addiction.” D. “I will not be allowed to take any narcotics for pain during my hospital admission.”.

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).

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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 health care provider orders a trough level of an antibiotic administered every twenty four hours. When should the nurse plan for a trough level to be drawn?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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