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:
"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.
Correct Answer is C
Explanation
The correct answer is choice C, frequent swallowing.
This indicates that the child may be experiencing hemorrhage because they are trying to clear the blood from their throat. Frequent swallowing is one of the initial signs of bleeding immediately after tonsillectomy.
Choice A is wrong because elevated pain level is not a specific sign of hemorrhage.
Pain is expected after a tonsillectomy and can be managed with medication and fluids.
Choice B is wrong because increased drowsiness is not a specific sign of hemorrhage.
Drowsiness can be caused by anesthesia, medication, or dehydration.
Choice D is wrong because diminished breath sounds are not a specific sign of hemorrhage.
Diminished breath sounds can be caused by respiratory infection, asthma, or bronchospasm.
Normal ranges for hemoglobin and hematocrit are 11.5 to 15.5 g/dL and 34 to 45% for children, respectively.
Normal ranges for platelet count are 150,000 to 450,000/mm3 for both children and adults.
Normal ranges for plasma clotting variables depend on the specific test and method used.
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