how should a nurse care for a patient with a tracheostomy

ATI RN

ATI RN Exit Exam

1. How should a healthcare provider care for a patient with a tracheostomy?

A. Clean the tracheostomy site daily
B. Change the tracheostomy ties daily
C. Suction the tracheostomy regularly
D. Provide humidified oxygen

Correct answer: C

Rationale: Suctioning the tracheostomy regularly is crucial in caring for a patient with a tracheostomy as it helps keep the airway clear of secretions, preventing blockages and potential complications. Cleaning the tracheostomy site daily is important for hygiene but not as critical as regular suctioning. Changing the tracheostomy ties daily may not be necessary unless soiled or loose. Providing humidified oxygen may be part of the care plan but is not as directly related to maintaining the tracheostomy patency as suctioning.

2. Which lab test is used to assess renal function?

A. Check blood glucose levels
B. Monitor serum creatinine
C. Monitor BUN
D. Check electrolyte levels

Correct answer: B

Rationale: The correct answer is B: Monitor serum creatinine. Serum creatinine is a key indicator of renal function as it reflects the glomerular filtration rate. An increase in serum creatinine levels indicates impaired kidney function. Checking blood glucose levels (choice A) is not specific to assessing renal function but is used to diagnose diabetes. Monitoring BUN (choice C) is important but not as specific as serum creatinine in assessing renal function. Checking electrolyte levels (choice D) is essential in assessing kidney function but is not as specific as monitoring serum creatinine.

3. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

A. I can give you information about respite care if you are interested.
B. You should consider taking a sleeping pill before bed each night.
C. It must be difficult taking care of someone who is terminally ill.
D. You are doing a great job taking care of your mother.

Correct answer: A

Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.

4. A nurse is providing teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?

A. Avoid taking this medication with antacids.
B. Contact your provider if you experience visual changes.
C. Increase your intake of foods high in potassium.
D. You may experience increased urination while taking this medication.

Correct answer: B

Rationale: The correct answer is B: 'Contact your provider if you experience visual changes.' Visual changes, such as blurred or yellow vision, can indicate digoxin toxicity and should be reported immediately to the healthcare provider for further evaluation and management. Choice A is incorrect because digoxin can be taken with antacids. Choice C is incorrect because increasing potassium intake can lead to hyperkalemia when taking digoxin. Choice D is incorrect because increased urination is not a common side effect of digoxin.

5. What is the best way to assess for fluid overload in a patient with heart failure?

A. Check daily weight
B. Check blood pressure
C. Monitor heart sounds
D. Assess for jugular vein distention

Correct answer: A

Rationale: The correct answer is to 'Check daily weight.' Monitoring daily weight is the most accurate method to assess for fluid overload in patients with heart failure. Weight gain can indicate fluid retention, a common issue in heart failure patients. Checking blood pressure (Choice B) can provide information about hemodynamic status but may not be as specific for fluid overload as monitoring weight. Monitoring heart sounds (Choice C) can provide information about cardiac function but may not directly assess fluid overload. Assessing for jugular vein distention (Choice D) can be a sign of increased central venous pressure but may not always correlate with fluid overload as accurately as daily weight checks.