A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Secure the tracheostomy ties to allow one finger to fit snugly underneath.

Use a cotton tip applicator to clean inside the inner cannula.

Cleanse the skin around the stoma with normal saline.

Soak the outer cannula in warm, soapy tap water.

Answer and Explanation

The Correct Answer is A

When caring for a client who has a tracheostomy, the nurse should secure the tracheostomy ties to allow one finger to fit snugly underneath. This helps ensure that the tracheostomy tube is secure and prevents accidental dislodgement.
b)   A cotton tip applicator should not be used to clean inside the inner cannula as it can leave fibers behind
and increase the risk of infection.
c)   The skin around the stoma should be cleansed with sterile saline, not normal saline, to reduce the risk of infection.
d)   The outer cannula should not be soaked in warm, soapy tap water as this can introduce bacteria and increase the risk of infection.

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Correct Answer is D

Explanation

When a nurse receives a new prescription over the telephone from a client's provider, the first action the nurse should take is to write down the complete prescription. This ensures that the nurse has an accurate record of the prescription and can refer to it when administering medication or providing care.

Option a is incorrect because documenting the prescription as a telephone prescription in the medical record is important but not the first action.

Option b is incorrect because reading back the prescription to the provider is important but not the first action.

Option c is incorrect because ensuring that the provider signs the prescription is important but not the first action.

A. Fever B. Crackles in the lungs C. Bradycardia D. Flattened neck veins

Correct Answer is B

Explanation

Crackles in the lungs indicate that the client is experiencing ﬂuid overload. When there is an excess of ﬂuid in the body, it can accumulate in the lungs and cause crackles. The other

a. Fever is not a sign of ﬂuid overload.

c. Bradycardia (a slow heart rate) is not a sign of ﬂuid overload.

d. Flattened neck veins are not a sign of ﬂuid overload; distended neck veins may be a sign of ﬂuid overload.

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A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is assessing a client who is receiving continuous IV ﬂuids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing ﬂuid overload?

Correct Answer is B

Explanation

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