A home health nurse is providing education to a client discharged with a tracheostomy. Which statement by the client demonstrates teaching has been effective?

“My spouse should always take care of my tracheostomy. I should not do it myself.”.

“I am the only one who needs to know how to suction my tracheostomy at home.”.

“I can use my saline for longer than 24 hours if I boil it.”.

“I can use clean instead of sterile technique to suction my tracheostomy.”.

Answer and Explanation

The Correct Answer is D

“I can use clean instead of sterile technique to suction my tracheostomy.” This statement demonstrates that the client understands how to care for their tracheostomy at home. According to the American Thoracic Society, clean technique can be used for suctioning at home, as long as the equipment is cleaned and stored properly.

Choice A is wrong because the client should be able to take care of their own tracheostomy as much as possible, with the help of a caregiver if needed. This promotes independence and self-care.

Choice B is wrong because the client should not be the only one who knows how to suction their tracheostomy at home. They should have at least one backup person who can assist them in case of an emergency or if they are unable to do it themselves.

Choice C is wrong because the client should not use saline for longer than 24 hours, even if they boil it.

Saline can become contaminated with bacteria and cause infection. The client should use fresh saline every time they suction their tracheostomy.

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Correct Answer is B

Explanation

Leave the needle in place for at least 10 seconds before removing it to trap the medication in the muscle.

The Z-track method is a technique used to administer intramuscular injections that prevent leakage of medication into the subcutaneous tissue. The nurse should pull the skin laterally before inserting the needle, inject the medication slowly, leave the needle in place for at least 10 seconds, and release the skin after withdrawing the needle.

Choice A is wrong because the total volume of the injection is not limited to 1 milliliter in the Z-track method. The Z-track method can be used to administer up to 3 milliliters of medication depending on the site and muscle mass of the client.

Choice C is wrong because the needle size and gauge depend on the site, medication, and client characteristics, not on the Z-track method. The Z-track method can be performed with different needle sizes and gauges as long as they are appropriate for intramuscular injections.

Choice D is wrong because the nurse should not administer the medication rapidly in the Z- track method.

Rapid injection can cause pain, tissue damage, and leakage of medication into the subcutaneous tissue. The nurse should inject the medication slowly and steadily in the Z-track method.

A. Chicken, carrots, and fresh grapefruit salad. B. Salmon, turnip greens, brown rice, and an orange. C. Green salad, ground beef patty, corn, and applesauce. D. Plain omelet, bacon, toast with butter, and strawberries.

Correct Answer is B

Explanation

This meal selection best demonstrates a client with osteoporosis understands dietary recommendations because it provides adequate amounts of calcium, vitamin D, and protein, which are essential nutrients for bone health.

Choice A is wrong because chicken, carrots, and fresh grapefruit salad do not provide enough calcium or vitamin D for a person with osteoporosis.

Calcium is mainly found in dairy products, leafy green vegetables, and fish with bones. Vitamin D is mainly found in fatty fish, egg yolks, and fortified foods.

Choice C is wrong because green salad, ground beef patty, corn, and applesauce do not provide enough calcium or vitamin D for a person with osteoporosis.

Green salad may contain some calcium depending on the type of greens, but it is not a rich source.

Ground beef patty and corn are low in calcium and vitamin

D. Applesauce does not contain any calcium or vitamin

D. Choice D is wrong because plain omelet, bacon, toast with butter, and strawberries do not provide enough calcium or vitamin D for a person with osteoporosis.

Plain omelet and bacon are high in protein but low in calcium and vitamin

Toast with butter may contain some vitamin D if the bread or butter are fortified, but it is not a rich source.

Strawberries do not contain any calcium or vitamin

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A home health nurse is providing education to a client discharged with a tracheostomy. Which statement by the client demonstrates teaching has been effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action should a nurse perform when administering an intramuscular injection via the Z- track method?

Correct Answer is B

Explanation

Which meal selection best demonstrates a client with osteoporosis understands dietary recommendations?

Correct Answer is B

Explanation

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Which client assessment should a nurse immediately report to the health care provider?

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A client has lorazepam prescribed before surgery and refuses the injection. If the nurse administers the scheduled injection despite the client’s lack of consent, which term best describes the nurse’s action?

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A nurse assessing a client’s lung sounds hears continuous low-pitched harsh rattling sounds over the client’s trachea that are most evident on expiration and are decreased after coughing. Which term is the appropriate choice to accurately document this lung sound?