what are the nursing interventions for a patient with a tracheostomy

ATI LPN

ATI PN Comprehensive Predictor

1. What are the key nursing interventions for a patient with a tracheostomy?

A. Maintain a patent airway and monitor for infection
B. Suction airway secretions and provide humidified oxygen
C. Educate patient on self-care and tracheostomy cleaning
D. Change tracheostomy ties daily

Correct answer: A

Rationale: The correct answer is to maintain a patent airway and monitor for infection. These are crucial nursing interventions for patients with tracheostomies to ensure adequate oxygenation and prevent complications. Suctioning airway secretions and providing humidified oxygen can be part of the care plan but are not as essential as maintaining a patent airway. Educating the patient on self-care and tracheostomy cleaning is important for long-term management but is not as immediate as ensuring a patent airway and monitoring for infection. Changing tracheostomy ties daily is a specific task related to tracheostomy care but is not as critical as ensuring the airway is clear and infection-free.

2. What is the nurse's role in preoperative patient care?

A. Provide patient education and ensure NPO status
B. Ensure that informed consent is obtained
C. Obtain the patient's health history
D. Confirm the patient's surgical site

Correct answer: A

Rationale: The nurse plays a crucial role in preoperative patient care by providing education and ensuring NPO (nothing by mouth) status. This helps prepare the patient for surgery by ensuring they understand the procedure, what to expect, and also by following necessary preoperative fasting guidelines. While obtaining the patient's health history (choice C) is important for overall patient assessment, it is typically done during the preoperative assessment but does not specifically pertain to the nurse's role. Ensuring informed consent (choice B) is primarily the responsibility of the healthcare provider performing the procedure. Confirming the patient's surgical site (choice D) is usually the responsibility of the surgical team and is done immediately before the surgery to prevent errors.

3. What is the best teaching point for a client with left-leg weakness learning to use a cane?

A. Use the cane on the weaker side
B. Maintain two points of support on the floor at all times
C. Advance the cane 30 to 45 cm with each step
D. Advance the cane and the strong leg together

Correct answer: B

Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures better stability and support for the client while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice C is incorrect as advancing the cane too far with each step may compromise balance. Choice D is incorrect because advancing the cane and the strong leg together may not provide adequate support for the weaker leg.

4. A nurse is caring for a client following an acute myocardial infarction who is concerned about fatigue. What is the best strategy to promote independence in self-care?

A. Instruct the client to remain in bed until the fatigue resolves
B. Encourage the client to gradually resume self-care tasks with frequent rest periods
C. Assign assistive personnel to perform all self-care tasks for the client
D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence while managing fatigue. This approach allows the client to regain confidence in their abilities and fosters independence. Option A is incorrect as prolonged bed rest can lead to deconditioning and worsen fatigue. Option C is not promoting independence as it involves delegating all self-care tasks to others. Option D involves family assistance, which may be helpful but does not directly promote the client's independence in self-care.

5. What is the priority when managing a client with a chest tube postoperatively?

A. Clamp the chest tube for 30 minutes every 4 hours
B. Check for air leaks and proper functioning of the chest tube
C. Encourage deep breathing and coughing every 2 hours
D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The priority when managing a client with a chest tube postoperatively is to check for air leaks and ensure the proper functioning of the chest tube. This is crucial to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube intermittently can lead to a buildup of pressure in the pleural space and should not be done without a specific medical indication. Encouraging deep breathing and coughing helps with lung expansion but is not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing may increase the risk of dislodging the chest tube or causing complications.