A nurse is providing discharge teaching to the partner of a client who has a tracheostomy.
Which of the following information should the nurse include in the teaching
How to change the nondisposable tracheostomy tube daily.
How to operate the portable suction machine.
How to change the tracheostomy dressing using clean technique
How to secure the tracheostomy tube with ties at the back of the neck
The Correct Answer is B
The correct answer is choice B. How to operate the portable suction machine. The nurse should include this information in the teaching because suctioning is often needed to keep the tracheostomy tube and opening free from extra mucus and secretions that come from the lungs and tissue around the stoma. Suctioning can help prevent the tube from becoming plugged and improve breathing.
Choice A is wrong because the nondisposable tracheostomy tube does not need to be changed daily. It can be changed every 1 to 3 months, depending on the type of tube.
Choice C is wrong because the tracheostomy dressing should be changed using sterile technique, not clean technique, to prevent infection.
Choice D is wrong because the tracheostomy tube should not be secured with ties at the back of the neck. The ties should be fastened at the front or side of the neck, and they should be snug but not too tight.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason
The anterior fontanel is open is the correct answer. An expected finding in an 8-month-old infant is that the anterior fontanel (the soft spot on the top of the baby's head) is open. The fontanelles are spaces between the bones of an infant's skull that allow for the baby's brain to grow and the skull to mould during birth.
The anterior fontanel typically remains open until the baby is around 18 to 24 months old, with the closure process starting sometime after 9 months of age. Therefore, at 8 months of age, it is normal for the anterior fontanel to still be open.
Choice B reason:
Both fontanels are the same size is incorrect. Both fontanels are usually not the same size. The anterior fontanel is larger and diamond-shaped, while the posterior fontanel is smaller and triangular.
Choice C reason:
The posterior fontanel is open is incorrect. The posterior fontanel, located at the back of the baby's head, usually closes earlier than the anterior fontanel. It typically closes within the first few months after birth, so it is not expected to be open at 8 months of age.
Choice D reason
Both fontanels show molding is incorrect. Molding refers to the temporary shaping of the baby's head during birth due to the pressure exerted during the passage through the birth canal. By 8 months of age, the molding typically resolves, and the baby's head should have a more rounded appearance.
Correct Answer is A
Explanation
This is because glass ampules can leave small shards of glass in the solution, which can be harmful if injected into the client. A filter needle has a small mesh that traps any glass particles and prevents them from entering the syringe.
Choice B is wrong because the nurse should break the neck of the ampule away from their body to avoid injury from the glass.
Choice C is wrong because the nurse should use a different needle to inject the client after withdrawing the medication with a filter needle. This is to prevent contamination and reduce pain for the client.
Choice D is wrong because the nurse should dispose of the ampule in a sharps container, not in the trash can. This is to prevent injury and infection from the broken glass.
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