A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?

Verbalizing all steps in the procedure

Attending a class given about tracheostomy care

Performing the procedure independently

Asking appropriate questions about suctioning

Answer and Explanation

The Correct Answer is C

A. Verbalizing steps is important for understanding but does not demonstrate the ability to perform the procedure.
B. Attending a class is beneficial for learning, but it does not confirm the partner’s practical competence.
C. Performing the procedure independently indicates that the partner can effectively manage suctioning without supervision, demonstrating readiness for discharge.
D. Asking questions is a sign of engagement but does not show practical readiness.

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Correct Answer is D

Explanation

A. Holding the client's arms and legs can cause injury and does not help in managing the seizure. The focus should be on protecting the client from harm.
B. Moving the client back to bed during a seizure can be dangerous and increase the risk of injury. It's best to manage the seizure where the client is.
C. Inserting a tongue blade or any object into the client's mouth can cause injury to the teeth or oral cavity and is not recommended during a seizure.
D. Placing the client on his side helps maintain an open airway and prevents aspiration, which is crucial during a seizure to ensure the client’s safety.

A. Reduce the client's intake of protein. B. Restrict the client's intake of fluids. C. Administer vitamin K D. Administer diuretics.

Correct Answer is A

Explanation

A. Reducing protein intake is a key intervention to decrease ammonia levels in clients with liver cirrhosis and encephalopathy. Protein metabolism in the liver produces ammonia, and limiting protein can help manage elevated ammonia levels, thereby reducing symptoms of encephalopathy.

B. Restricting fluid intake is not directly related to decreasing ammonia levels. While fluid restriction may be necessary in cases of ascites or edema, it does not address the root cause of elevated ammonia in liver disease.

C. Administering vitamin K is important for managing clotting issues in liver disease but does not directly impact ammonia levels. Vitamin K helps with clotting factor synthesis, which is not directly related to ammonia metabolism.

D. Administering diuretics can help manage fluid retention but does not reduce ammonia levels. The primary goal for managing ammonia in cirrhosis involves dietary modifications and medications like lactulose, rather than diuretics.

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A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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