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 D

Explanation

Rationale:
A. Verify the alarm settings on the ventilator: Ensuring alarms are properly set is a routine safety check but does not directly address the client's agitation or risk of self-extubation. It is important but not the priority action in this scenario.

B. Turn on the television: Providing distraction may help reduce mild anxiety but is insufficient for managing significant agitation in a mechanically ventilated client who may become dangerous to themselves if they pull out the endotracheal tube.

C. Obtain a prescription for a vest restraint: Physical restraints should be a last resort after attempting less restrictive methods. Using restraints without addressing the underlying cause of agitation (e.g., discomfort, anxiety, pain) can increase distress and injury risk.

D. Administer a sedative medication: Sedation is appropriate for a mechanically ventilated client who is agitated and at risk for self-extubation. Sedatives help ensure patient comfort, reduce anxiety, and promote ventilator synchrony while protecting the airway.

A. Blurred vision B. Tinnitus C. Peripheral edema D. Bradycardia

Correct Answer is A

Explanation

Rationale:
A. Blurred vision: Ethambutol is known to cause optic neuritis, which can lead to blurred vision, decreased visual acuity, and impaired red-green color discrimination. Clients on ethambutol should be monitored for changes in vision and advised to report any visual disturbances immediately.

B. Tinnitus: Tinnitus is not a typical adverse effect of ethambutol. It is more commonly associated with other anti-tuberculosis drugs such as streptomycin, which can cause ototoxicity, especially affecting the auditory and vestibular systems.

C. Peripheral edema: Peripheral edema is not commonly linked to ethambutol use. It may occur with certain cardiovascular medications or conditions but is not an expected side effect of this antitubercular drug.

D. Bradycardia: Bradycardia is not a recognized adverse effect of ethambutol. This medication primarily affects the eyes rather than the cardiovascular system. Monitoring for vision changes is a higher priority when assessing for side effects.

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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 caring for a client who is mechanically ventilated and is agitated. The nurse notices the client attempts to reach the endotracheal tube. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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