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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Correct Answer is C
Explanation
The correct answer is choice C. Holding the client’s eyes shut for a few seconds.
This is because the eyes of a deceased client do not close naturally and may remain open after death. Holding them shut for a few seconds helps to keep them closed and prevent drying of the corneas.
This also gives a more peaceful appearance to the client’s body for the family visit.
Choice A is wrong because crossing the client’s arms across their chest is not a standard postmortem care procedure. It may also interfere with the placement of identification tags on the wrists.
Choice B is wrong because placing the client in a high-Fowler’s position is not necessary or appropriate for postmortem care. The client should be placed in a supine position with the head of the bed elevated to prevent livor mortis (purple discoloration of the skin) on the face.
Choice D is wrong because removing the client’s dentures from their mouth is not recommended for postmortem care. The dentures should be left in place to maintain the shape of the face and prevent the jaw from dropping.
Normal ranges are not applicable for this question as it does not involve any physiological measurements.
Correct Answer is A
Explanation
Choice A reason:
"Plan to take this medication with food." Is the correct statement. When providing instructions to an older adult client who has a seizure disorder and is prescribed phenytoin (an antiepileptic or anticonvulsant medication), the nurse should advise the client to take the medication with food. Phenytoin can cause gastrointestinal irritation, and taking it with food can help minimize this side effect.
Choice B reason:
"Plan to take this medication with antacids. “is not the appropriate instruction. Phenytoin should not be taken with antacids. Antacids can reduce the absorption of phenytoin, leading to decreased effectiveness of the medication. If antacids are needed for other reasons, they should be taken at least 2 hours before or after taking phenytoin.
Choice C reason:
"Limit foods that contain vitamin D while taking this medication. “This is not inappropriate instruction. There is no specific requirement to limit foods containing vitamin D while taking phenytoin. However, phenytoin may decrease the absorption of vitamin D, which could potentially affect the client's vitamin D levels. Therefore, it is essential for the client to have regular check-ups and possibly discuss the need for vitamin D supplementation with their healthcare provider.
Choice D reason:
"Limit foods that contain folic acid while taking this medication. “This is not the correct statement. Phenytoin can interfere with the absorption of folic acid (a B-vitamin). Long-term use of phenytoin may lead to folic acid deficiency. Therefore, the nurse should instruct the client to consume foods rich in folic acid and discuss the potential need for folic acid supplementation with their healthcare provider.
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