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?

Performing the procedure independently

Attending a class given about tracheostomy care

Verbalizing all steps in the procedure

Asking appropriate questions about suctioning

Answer and Explanation

The Correct Answer is A

Performing the procedure independently is the best indicator of the partner's readiness for the client's discharge, as it demonstrates competence and confidence in suctioning. Suctioning is a skill that requires practice and supervision until mastery is achieved. The nurse should observe and evaluate the partner's performance of suctioning and provide feedback and reinforcement as needed.

b)   Attending a class given about tracheostomy care is a good action by the partner, but not the best indicator of readiness for the client's discharge. Attending a class can provide information and education about tracheostomy care, but it does not necessarily translate into skill acquisition or application. The nurse should assess the partner's understanding and retention of the information and provide additional teaching or clarification as needed.
c)   Verbalizing all steps in the procedure is a good action by the partner, but not the best indicator of readiness for the client's discharge. Verbalizing all steps in the procedure can help the partner remember and follow the correct sequence and technique of suctioning, but it does not necessarily reﬂect actual performance or ability. The nurse should observe and verify that the partner is doing what they are saying and correct any errors or omissions as needed.
d)   Asking appropriate questions about suctioning is a good action by the partner, but not the best indicator of readiness for the client's discharge. Asking appropriate questions about suctioning can show interest and involvement in learning and caring for the client, but it does not necessarily indicate competence or confidence in suctioning. The nurse should answer the partner's questions and provide additional resources or referrals as needed.

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Correct Answer is C

Explanation

Continuing to monitor the client is the appropriate action for the nurse to take, as a rise in the water seal chamber with client inspiration is a normal and expected finding. The water seal chamber acts as a one-way valve that allows air to exit from the pleural space and prevents air from entering. The water level in this chamber ﬂuctuates with breathing, rising with inspiration and falling with expiration. This indicates that the chest tube system is functioning properly and that there is no air leak.

a) Immediately notifying the provider is not necessary, as a rise in the water seal chamber with client inspiration is not an abnormal or urgent finding. The nurse should only notify the provider if there are signs of complications, such as persistent bubbling in the water seal chamber, which indicates an air leak, or no ﬂuctuation in the water level, which indicates an obstruction or resolution of pneumothorax.
b) Clamping the chest tube near the water seal is not advisable, as it can cause increased pressure in the pleural space and lead to tension pneumothorax. Clamping the chest tube should only be done for a brief period of time and under specific circumstances, such as changing the drainage system, assessing for an air leak, or preparing for chest tube removal.
d) Repositioning the client toward the left side is not helpful, as it does not aﬀect the water level in the water seal chamber. The nurse should position the client according to their comfort and condition, and avoid placing them ﬂat or on their aﬀected side, as this can impair drainage and ventilation.

Correct Answer is ["10"]

Explanation

To calculate the amount of mL to administer, the nurse should use the following formula:

(mg ordered / mg available) x mL available = mL to administer

Substituting the values from the question, the nurse should do the following:

(500 mg / 250 mg) x 5 mL = 10 mL

Therefore, the nurse should administer 10 mL of amoxicillin suspension.

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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 three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?

Correct Answer is C

Explanation

A nurse is preparing to administer amoxicillin 500 mg PO every 12 hr. The amount available is amoxicillin 250 mg/5 mL suspension. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["10"]

Explanation

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