a nurse is implementing a plan of care for a client with a tracheostomy when should the nurse suction the client
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. When should a nurse suction a client with a tracheostomy?

Correct answer: C

Rationale: The correct answer is to suction the client when they show signs of irritability. Signs of irritability, such as restlessness or agitation, can indicate the need for suctioning in a client with a tracheostomy. This early indicator suggests that there may be an accumulation of secretions affecting the client's airway. Suctioning should be performed promptly to maintain a clear airway and prevent complications. Choices A, B, and D are incorrect because suctioning should be based on clinical signs and symptoms indicating the need for intervention, rather than a fixed schedule or specific vital sign parameters.

2. A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: 'Furrows in the tongue.' Dehydration commonly presents with furrows in the tongue due to decreased oral moisture. This physical finding indicates dehydration as the tongue loses moisture and becomes dry. Choice A, 'Bradycardia,' is not typically associated with dehydration; instead, tachycardia may be present as a compensatory mechanism. Elevated blood pressure, as mentioned in choice B, is not a typical finding in dehydration; in fact, dehydration often leads to a decrease in blood pressure. Polyuria, as in choice D, is more commonly associated with conditions like diabetes mellitus or diabetes insipidus, rather than dehydration.

3. What are the signs and symptoms of a pulmonary embolism?

Correct answer: D

Rationale: A pulmonary embolism can manifest with sudden shortness of breath, chest pain, and coughing up blood. These symptoms are classic presentations of a pulmonary embolism due to the blockage of blood flow to the lungs. Therefore, the correct answer is 'All of the above.' Each symptom alone can be seen in various other conditions, but when occurring together, they strongly suggest a pulmonary embolism. Sudden shortness of breath is due to decreased oxygenation, chest pain can result from the strain on the heart, and coughing with blood may indicate damage to the lung tissue. Choosing any single symptom would not encompass the full range of presentations seen in a pulmonary embolism.

4. A healthcare provider is checking a newborn's vital signs. Which of the following methods of temperature measurement should the healthcare provider use?

Correct answer: B

Rationale: The axillary method is the most appropriate for newborns because it is non-invasive and safe. Rectal temperature measurement can be uncomfortable and poses a risk of injury, especially in newborns. Oral temperature measurement is not recommended for newborns due to their inability to cooperate and potential inaccuracies. Tympanic temperature measurement may not be as accurate in newborns compared to older children or adults.

5. What are the common signs and symptoms of dehydration in the elderly?

Correct answer: A

Rationale: Corrected Rationale: Dehydration in the elderly is often signaled by dry mouth, confusion, and decreased skin turgor due to reduced fluid intake. Choice A is the correct answer as these are common signs and symptoms of dehydration in the elderly.\nIncorrect Rationales: Option B (Increased heart rate and muscle cramps) are more associated with conditions like hyperthyroidism or electrolyte imbalances rather than dehydration. Option C (Fever, rapid breathing, and increased urine output) are signs of other medical conditions such as infections or diabetes insipidus. Option D (Increased thirst and difficulty walking) can be seen in various situations but are not specific signs of dehydration in the elderly.

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