a charge nurse is observing a newly licensed nurse perform tracheostomy care for a client which of the following actions by the newly licensed nurse r
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Fundamentals of Nursing HESI

1. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

Correct answer: A

Rationale: The correct answer is A. Obtaining cotton balls for tracheostomy care is not recommended due to the risk of fiber contamination. Sterile gauze should be used instead. Choice B, using a sterile water bottle, is a correct and appropriate action for tracheostomy care to maintain cleanliness. Choice C, checking the suction equipment, is also a necessary step to ensure it is functioning properly for the procedure. Choice D, wearing a sterile gown, is a standard precaution to maintain a sterile environment during tracheostomy care.

2. A healthcare professional is preparing to administer metoprolol 200 mg PO daily. The medication available is metoprolol 100 mg/tablet. How many tablets should the healthcare professional administer? (Round the answer to the nearest whole number. Do not use a trailing zero.)

Correct answer: B

Rationale: To administer 200 mg of metoprolol using 100 mg tablets, the healthcare professional should give 2 tablets. Each tablet contains 100 mg of metoprolol, so 2 tablets will provide the required 200 mg dose. Choice A is incorrect because 1 tablet would only provide 100 mg, which is insufficient. Choice C is incorrect as fractions of tablets are usually not used in practice to ensure accurate dosing. Choice D is incorrect as it would result in an overdose, providing 400 mg instead of the prescribed 200 mg.

3. A client expresses that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make?

Correct answer: D

Rationale: The correct response is to involve the client's religious and spiritual leaders in the discussion to find a solution that respects both the client's values and medical needs. Option A is incorrect as it dismisses the client's beliefs. Option B assumes the family's opinion over the client's. Option C is inappropriate as it questions the client's religious beliefs rather than addressing the concern respectfully.

4. A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

Correct answer: A

Rationale: When a client with an indwelling catheter reports a need to urinate, the nurse's initial action should be to check the catheter for patency. This is crucial to ensure that the catheter is not blocked, twisted, or kinked, which could lead to urinary retention. Reassuring the client without assessing the catheter could delay necessary interventions. Re-catheterizing the bladder with a larger-gauge catheter should not be the first step unless catheter patency is confirmed as an issue. Collecting a urine specimen for analysis is important but not the immediate priority when the client reports a need to urinate.

5. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?

Correct answer: B

Rationale: The correct answer is 'Watermelon.' Watermelon is high in potassium, which is important to counteract the potassium loss caused by furosemide. Furosemide is a loop diuretic that can lead to potassium depletion, so consuming potassium-rich foods like watermelon can help maintain electrolyte balance. Choices A, C, and D do not specifically address the need for potassium in this scenario and are not as beneficial for addressing the potential electrolyte imbalance caused by furosemide.

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