a nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take when providing tracheostomy care a nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take when providing tracheostomy care
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

1. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care?

Correct answer: C

Rationale: The correct answer is to use a sterile brush to clean the inner cannula. This action is crucial to prevent infection during tracheostomy care. Choice A is incorrect as clean technique is not adequate for tracheostomy care, sterile technique is required. Choice B is incorrect as tracheostomy ties should be replaced when soiled, not routinely every 24 hours. Choice D is incorrect as tracheostomy dressings should be changed more frequently to maintain cleanliness and prevent infection.

2. How much extra protein (above RDA) is safe to consume?

Correct answer: A

Rationale: Consuming up to twice the Recommended Dietary Allowance (RDA) of protein is generally considered safe for most people, although it may vary depending on individual health conditions.

3. A dietitian tells you that you are not consuming enough calories. Which of the following nutrients could you add to your diet to increase your energy intake?

Correct answer: C

Rationale: Corrected Rationale: Protein provides 4 kcal per gram, making it a good source of energy to increase caloric intake. While fiber and water are important for other aspects of health, they do not provide energy like protein does. Vitamins are essential for various bodily functions but do not contribute directly to caloric intake.

4. According to Piaget, a 6-month-old infant should be in which developmental stage?

Correct answer: C

Rationale: By 6 months, infants are usually in the stage of secondary circular reactions, where they start to intentionally repeat actions that bring pleasure or interesting results.

5. Rhabdomyolysis can result in serious complications. In addition to muscle pain and weakness, a patient will complain of:

Correct answer: dark urine.

Rationale: The correct answer is dark urine. Rhabdomyolysis is a condition characterized by the breakdown of muscle tissue, leading to the release of myoglobin into the bloodstream. Myoglobin can cause the urine to appear dark or tea-colored, a condition known as myoglobinuria. This is a classic symptom of rhabdomyolysis. Choices A, B, and D are incorrect as they do not typically present as direct symptoms of rhabdomyolysis. Paresthesias refer to abnormal sensations like tingling or numbness, bone pain is not a primary symptom of rhabdomyolysis, and diarrhea is not a common complaint associated with this condition.

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