mr landon is to have a tracheostomy performed which of the following actions is most appropriate for the nurse to take when suctioning the tracheostom
Logo

Nursing Elites

HESI RN

HESI Fundamentals

1. When suctioning a tracheostomy, which action is most appropriate for the nurse to take?

Correct answer: B

Rationale: When suctioning a tracheostomy, it is crucial to use sterile technique to prevent infections. Turning off the suction as the catheter is introduced is important to avoid trauma and injury to the tracheal walls. This technique helps maintain the integrity of the tracheostomy site and ensures proper care for the patient.

2. Prior to Mr. Landon undergoing a tracheostomy, what is the top nursing priority?

Correct answer: B

Rationale: Before Mr. Landon undergoes a tracheostomy, the top nursing priority is to establish a means of communication. This is essential to ensure that Mr. Landon can effectively communicate his needs during and after the procedure. Shaving the neck (Choice A) may be necessary for the tracheostomy but is not the top priority. Inserting a Foley catheter (Choice C) and starting an IV (Choice D) are important nursing interventions but are not the priority before a tracheostomy procedure, where communication is key for patient safety and comfort.

3. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?

Correct answer: C

Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. This finding indicates dehydration and the need to restore the client's fluid volume. Therefore, the appropriate action for the nurse is to continue the planned nursing interventions aimed at addressing the fluid deficit. Choice A is incorrect as jugular vein distention is associated with fluid overload, not deficit. Choice B is incorrect as offering high-protein snacks does not directly address the fluid volume deficit. Choice D is incorrect as the priority is to address the fluid deficit before addressing skin integrity issues.

4. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

Correct answer: C

Rationale: To assess fever patterns accurately, the nurse should measure the client’s temperature at regular intervals. This approach helps in identifying the pattern of fever spikes and fluctuations, which can provide valuable information for diagnostic and treatment purposes. Assessing for flushed, warm skin or documenting circadian rhythms may not directly reveal the fever pattern, while varying temperature measurement sites could lead to inconsistent readings. Therefore, measuring temperature at regular intervals is the most appropriate intervention to identify fever patterns in this scenario.

5. A client is admitted with a diagnosis of right-sided heart failure. What assessment finding should the nurse anticipate?

Correct answer: C

Rationale: In right-sided heart failure, the heart's inability to effectively pump blood to the lungs leads to fluid backup in the systemic circulation, resulting in peripheral edema (swelling in lower extremities). While jugular vein distention (A) and hepatomegaly (D) can also occur in right-sided heart failure, peripheral edema is a hallmark sign due to fluid retention. Crackles in the lungs (B) are more commonly associated with left-sided heart failure, where fluid accumulates in the lungs.

Similar Questions

What is the main purpose of the working phase of the nurse-patient relationship?
You are assigned to teach a student how to suction an adult patient with a tracheostomy. Which of the following actions by the student would be incorrect?
The nurse is providing discharge teaching to a client with a new prescription for warfarin (Coumadin). Which dietary instruction should the nurse include?
In a client with moderate, persistent, chronic neuropathic pain due to diabetic neuropathy who takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily, if Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?
A client with a history of myocardial infarction (MI) is admitted with chest pain. Which laboratory test should the nurse expect to be ordered to determine if the client is experiencing another MI?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses