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

Explanation

A. Bladder distension is a common trigger for autonomic dysreflexia in individuals with spinal cord injuries above T-6. It is crucial to manage bladder function to prevent this potentially life-threatening condition.

B. Elevated blood pressure is a sign of autonomic dysreflexia rather than a predisposing factor. Identifying the trigger, such as bladder distension, is essential before addressing the elevated blood pressure.

C. Nasal congestion is not typically associated with autonomic dysreflexia. While it might be uncomfortable, it is not a common trigger for this condition.

D. A severe headache can be a symptom of autonomic dysreflexia, but identifying the underlying cause or trigger, such as bladder distension, is essential for proper management.

A. Position the client in a high-Fowler's position if clear drainage is noted on the dressing. B. Assist the client into a knee-chest position to manage postoperative discomfort. C. Monitor sensory perception of the lower extremities. D. Maintain strict bed rest for the first 48 hr postoperative.

Correct Answer is C

Explanation

A. Positioning the client in a high-Fowler's position might not be appropriate immediately after a spinal fusion due to potential strain on the surgical site; the position should be adjusted based on specific postoperative orders.
B. The knee-chest position is not typically used postoperatively for a laminectomy with spinal fusion and could cause discomfort or complications.
C. Monitoring sensory perception of the lower extremities is crucial after spinal surgery to assess for potential complications such as nerve damage or compromised circulation.
D. Strict bed rest is not generally required for the entire first 48 hours; mobility and positioning should be based on the surgeon's recommendations and the client's tolerance.

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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 client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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