a nurse is caring for a client who has a tracheostomy which of the following interventions should the nurse implement when performing tracheostomy car
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Nursing Elites

ATI RN

Adult Medical Surgical ATI

1. When performing tracheostomy care, which intervention should the nurse implement?

Correct answer: C

Rationale: When caring for a client with a tracheostomy, it is essential to ensure that the airway is maintained and secured at all times. Securing new tracheostomy ties before removing the old ones helps prevent accidental decannulation and ensures continuous airway patency. Aseptic technique is crucial to prevent infections but is not directly related to securing the tracheostomy ties. Cleaning the inner cannula with mild soap and water is important for maintaining hygiene but does not address the immediate need for securing the airway. Applying suction when inserting the catheter is not a standard practice during tracheostomy care.

2. A nurse is caring for a client with a new diagnosis of type 1 diabetes. What is the most important aspect of teaching the nurse should focus on?

Correct answer: B

Rationale: Proper administration of insulin is crucial for clients with type 1 diabetes as they are dependent on insulin for blood glucose control.

3. A healthcare professional is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the professional expect to hear?

Correct answer: A

Rationale: When auscultating the lungs of a client with pleurisy, the healthcare professional should expect to hear loud, scratchy sounds. These sounds are characteristic of pleurisy, which is an inflammation of the pleura, causing a rough, grating sound during breathing.

4. A client with Parkinson's disease is prescribed carbidopa-levodopa (Sinemet). What should the nurse include in the teaching about this medication?

Correct answer: B

Rationale: Patients prescribed carbidopa-levodopa should be informed that it may take several weeks for the medication to reach its full therapeutic effectiveness in managing Parkinson's disease symptoms. This delayed onset of action is important for patients to be aware of to prevent premature discontinuation of the medication due to perceived lack of efficacy.

5. A healthcare professional is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the healthcare professional anticipate administering?

Correct answer: C

Rationale: In the scenario of a pulmonary embolism, the priority medication to administer is Heparin. Heparin is an anticoagulant that helps prevent the formation of new blood clots and the growth of existing ones, which is crucial in managing pulmonary embolism. Furosemide is a diuretic used to treat fluid retention, Dexamethasone is a corticosteroid used for inflammation, and Atropine is an anticholinergic medication used for various purposes such as treating bradycardia.

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