A nurse is providing discharge teaching for the family of a client who had a tracheostomy inserted 2 months ago. Which of the following instructions should the nurse include?

"Use the clean technique when suctioning."

"Clean the stoma site with full-strength hydrogen peroxide."

"Decrease the humidity level in your home."

"Remove soiled tracheostomy ties before replacing them."

Answer and Explanation

The Correct Answer is A

Rationale:
A. "Use the clean technique when suctioning.": For a well-established tracheostomy (typically after 1 month), clean technique is acceptable for suctioning at home. This reduces infection risk while allowing practical self-care or family-provided care in a non-sterile environment.

B. "Clean the stoma site with full-strength hydrogen peroxide.": Full-strength hydrogen peroxide is too harsh and can damage healthy tissue. A diluted solution or normal saline is safer for routine stoma care to avoid irritation and promote healing.

C. "Decrease the humidity level in your home.": Adequate humidity is essential for clients with tracheostomies to keep secretions thin and prevent airway blockage. Low humidity can dry the airway and increase the risk of mucus plugs.

D. "Remove soiled tracheostomy ties before replacing them.": Tracheostomy ties should be replaced one side at a time to prevent accidental decannulation. Removing both sides at once leaves the tracheostomy tube unsecured and poses a serious safety risk.

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Correct Answer is B

Explanation

Rationale:
A. Vitiligo: Vitiligo is an autoimmune condition characterized by depigmented patches of skin due to melanocyte destruction. It is more commonly associated with Addison's disease, not Cushing’s syndrome, which involves cortisol excess rather than deficiency.

B. Osteoporosis: Cushing's syndrome causes prolonged exposure to high cortisol levels, which inhibits bone formation and accelerates bone resorption. This leads to decreased bone density, making osteoporosis a common and expected finding in affected clients.

C. Myxedema: Myxedema refers to the severe hypothyroid state marked by non-pitting edema, dry skin, and slowed metabolism. It is associated with thyroid hormone deficiency, not the glucocorticoid excess seen in Cushing's syndrome.

D. Heat intolerance: Heat intolerance is a symptom more commonly linked to hyperthyroidism, where an increased metabolic rate leads to overheating. Clients with Cushing’s syndrome typically experience weight gain, fatigue, and cold intolerance rather than heat sensitivity.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"E"}

Explanation

Rationale:

Elevated blood glucose: A random glucose level of 220 mg/dL is mildly elevated and can be expected during acute illness or stress, especially in clients with diabetes. It should be monitored but does not require immediate intervention in this cardiac context.
Elevated heart rate: A heart rate of 116/min reflects tachycardia, which may result from pain, anxiety, or reduced cardiac output. While it is an important finding, it is secondary to more urgent issues like chest pain or myocardial injury.
Epigastric discomfort: Epigastric discomfort alone is not an emergency finding and can occur in non-cardiac conditions such as GERD or peptic ulcer disease. While it may signal atypical angina, it lacks the specificity or urgency of active chest pain.
Chest pain: Chest pain is a classic symptom of myocardial ischemia and warrants immediate intervention. The nurse should apply oxygen, initiate cardiac monitoring, assess pain characteristics, establish IV access, and prepare to administer nitroglycerin or aspirin per protocol.
Elevated troponin: A troponin level of 10.15 ng/mL confirms myocardial injury and supports the diagnosis of myocardial infarction. The nurse should report this result immediately, anticipate further cardiac workup, continue ECG and vital monitoring, and prepare the client for possible transfer to a higher level of care.
Elevated blood pressure: A BP of 158/92 mm Hg is elevated but not critical in this context. It is likely a response to pain or anxiety and can be managed after more urgent issues, such as ischemia or infarction, have been addressed.

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A nurse is providing discharge teaching for the family of a client who had a tracheostomy inserted 2 months ago. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

The nurse is continuing to care for the client following updates to the Nurses' Notes, Vital Signs, and Diagnostic Results. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client's dropdown followed by the client's dropdown

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"E"}

Explanation

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