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 ["A","B","C","H"]

Explanation

A. Potassium 7.0 mEq/L (3.5 to 5 mEq/L): Elevated potassium levels (hyperkalemia) can cause life-threatening cardiac arrhythmias and are especially concerning in clients with chronic kidney disease who are at risk of renal complications. Immediate follow-up is crucial to prevent severe cardiac effects.

B. WBC count 17,000/mm³ (Normal Finding: 5,000 to 10,000/mm³): An elevated WBC count indicates an infection or inflammation, which is concerning given the client’s symptoms and temperature. This finding requires immediate follow-up to address potential infection.

C. Crackles throughout lungs: Crackles may indicate fluid overload or pulmonary edema, particularly in clients with chronic kidney disease. This could be a sign of worsening renal function or heart failure, which requires prompt attention.

H. No dialysis for 24 hr: Missing dialysis sessions in a client with stage IV chronic kidney disease can lead to dangerous fluid and electrolyte imbalances. This finding requires immediate action to prevent complications related to renal failure.

Explanation of Incorrect Options:

E. Creatinine 3.0 mg/dL (0.5 to 1.3 mg/dL): While elevated creatinine levels are concerning, the client’s history of chronic kidney disease means this level is expected to be higher. However, it is not as immediately critical as the other findings.

F. Abdomen rigid with decreased bowel sounds: This may suggest abdominal complications but is not as immediately critical as issues related to hyperkalemia or infection.

G. Glucose 250 mg/dL: Elevated glucose levels are concerning but less immediately critical compared to severe electrolyte imbalances and potential infections.

H. Hemoglobin 10 g/dL (12 to 18 g/dL): Anemia is a concern but is not as urgent as the immediate risks posed by elevated potassium, signs of infection, or missed dialysis.

A. Obtain a prescription for pain medication. B. Discharge the client. C. Remove both of the elastic bandages from the leg. D. Obtain a prescription for the appropriate anti-venom.

Correct Answer is C

Explanation

A. While pain management may be necessary, it is not the priority in the initial management of a snake bite. The focus should be on addressing the potential spread of venom.

B. Discharging the client is not appropriate as the client requires immediate medical evaluation and treatment due to the venomous snake bite.

C. Removing the elastic bandages is crucial as they can impede blood flow and potentially exacerbate the spread of venom. Elastic bandages should not be used to constrict the limb; proper medical treatment is needed.

D. Obtaining a prescription for anti-venom is important but should be done after initial assessment and treatment of the snake bite. Removing constrictive bandages is the immediate action to take to manage the bite effectively.

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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

A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain. Exhibits Select the top 4 client findings that requires immediate follow up.

Correct Answer is ["A","B","C","H"]

Explanation

A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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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?

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