A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Secure the tracheostomy ties to allow one finger to fit snugly underneath.

Use a cotton tip applicator to clean inside the inner cannula.

Cleanse the skin around the stoma with normal saline.

Soak the outer cannula in warm, soapy tap water.

Answer and Explanation

The Correct Answer is A

When caring for a client who has a tracheostomy, the nurse should secure the tracheostomy ties to allow one finger to fit snugly underneath. This helps ensure that the tracheostomy tube is secure and prevents accidental dislodgement.
b)   A cotton tip applicator should not be used to clean inside the inner cannula as it can leave fibers behind
and increase the risk of infection.
c)   The skin around the stoma should be cleansed with sterile saline, not normal saline, to reduce the risk of infection.
d)   The outer cannula should not be soaked in warm, soapy tap water as this can introduce bacteria and increase the risk of infection.

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Correct Answer is B

Explanation

The correct answer is that the nurse should recommend the client to eat a light carbohydrate snack before bedtime. Eating a light carbohydrate snack before bedtime can help promote sleep by increasing the level of tryptophan in the brain, which can help induce sleep.

Options a, c and d are not appropriate interventions for insomnia. Taking a 30-min nap daily can disrupt nighttime sleep and worsen insomnia. Exercising 1 hr before bedtime can increase alertness and make it harder to fall asleep. Drinking a cup of hot cocoa before bedtime can also disrupt sleep due to its caﬀeine content.

A. Determine the probability of intervention-related complications. B. Review the potential benefits and consequences of each intervention. C. Select an intervention that provides the greatest benefit and least risk. D. Identify possible nursing interventions that address the client's nausea.

Correct Answer is D, B, A, C

Explanation

When caring for a client who is nauseated and unable to eat after taking an antibiotic, the nurse should first identify possible nursing interventions that address the client's nausea. The nurse should then review the potential benefits and consequences of each intervention. The nurse should determine the probability of intervention-related complications. Finally, the nurse should select an intervention that provides the greatest benefit and least risk to the client.

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A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

Correct Answer is B

Explanation

A nurse is caring for a client who is nauseated and unable to eat after taking an antibiotic. Identify the steps the nurse should take to address the client's nausea. (Arrange the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is D, B, A, C

Explanation

A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

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