mr landon is to have a tracheostomy performed while the nurse is suctioning a tracheostomy tube the client starts to cough what is the best action for
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Nursing Elites

HESI RN

HESI Fundamentals Quizlet

1. While suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?

Correct answer: B

Rationale: When a client coughs during tracheostomy tube suctioning, the nurse should gently withdraw the suction tubing. This action allows the client to cough out mucus naturally, reducing the risk of further irritation and promoting effective airway clearance. Choice A is incorrect because suctioning deeper can cause trauma and increase the risk of complications. Choice C is incorrect as removing the suction quickly may not allow the client to clear the mucus adequately. Choice D is incorrect as inserting and removing the suction multiple times can lead to unnecessary trauma and discomfort for the client.

2. What is the most important instruction for the nurse to provide a client with a new colostomy regarding stoma care?

Correct answer: C

Rationale: Measuring the stoma using a stoma guide (C) is crucial as it ensures that the appliance fits properly, which is essential for preventing skin irritation and leakage. Proper measurement helps in selecting the right size of the appliance, promoting comfort and optimal stoma care. In contrast, cleansing with hydrogen peroxide (A), applying a moisture barrier cream (B), and using a dry gauze pad (D) are important but not as critical as ensuring the correct fit of the stoma appliance.

3. One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, 'I think I will plan a big party for all my friends.' How should the nurse respond?

Correct answer: C

Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse. Choice A is discouraging and focuses on limitations. Choice B jumps to a conclusion and is not in line with the client's statement. Choice D dictates what the client should be doing, which is not respectful of the client's autonomy. Therefore, the most appropriate response is C, as it acknowledges the client's wishes and provides positive reinforcement without perpetuating denial.

4. A client is diagnosed with primary hypertension. Which assessment finding is most commonly associated with this diagnosis?

Correct answer: A

Rationale: Headache (A) is the most commonly associated symptom with primary hypertension due to increased pressure in the blood vessels, leading to headaches. While dizziness (B), fatigue (C), and edema (D) may also occur in hypertension, headache is the most frequently reported symptom among individuals with primary hypertension.

5. The healthcare provider identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection?

Correct answer: B

Rationale: Proper handwashing technique is crucial in preventing the transmission of infections, especially in clients with burns where the risk of infection is high. It is the most effective intervention to reduce the risk of contamination and promote healing in these clients. While plasma expanders, topical antibacterial creams, and visitor restrictions are important considerations in burn care, meticulous hand hygiene takes precedence in preventing infections. Handwashing helps remove pathogens that could lead to infections, making it essential in the care of clients with burns.

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