when caring for a patient with a fresh tracheostomy what is the nurses first priority
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Nursing Elites

HESI LPN

PN Exit Exam 2023 Quizlet

1. When caring for a patient with a fresh tracheostomy, what is the nurse’s first priority?

Correct answer: B

Rationale: The correct answer is B: Ensuring the tracheostomy ties are secure. This is the nurse's first priority because it is critical to prevent accidental decannulation, which could compromise the patient’s airway. Providing humidified oxygen, suctioning the tracheostomy tube, and monitoring for signs of infection are important aspects of care but ensuring the tracheostomy ties' security takes precedence to maintain the patient's airway.

2. Which type of isolation is required for a patient with measles?

Correct answer: B

Rationale: The correct answer is B: Airborne isolation. Measles is highly contagious and can be transmitted through airborne particles, so airborne isolation is necessary to prevent its spread. Choice A, Contact isolation, is incorrect because measles is not primarily transmitted through direct contact. Choice C, Droplet isolation, is also incorrect as measles is not transmitted through large droplets but through smaller airborne particles. Choice D, Reverse isolation, is used to protect a patient from outside infections, not to prevent the spread of a contagious disease like measles.

3. A female client taking a liquid iron preparation expresses concern that her tooth color has darkened since starting the medication. What action should the PN implement?

Correct answer: A

Rationale: The correct action for the PN to implement is to teach the client to use a straw when taking the medication to reduce further tooth staining. Using a straw minimizes contact between the iron preparation and the teeth, helping prevent additional staining. Choice B is incorrect because withholding doses without consulting the healthcare provider could be detrimental to the client's health. Choice C is incorrect because darkening of tooth color is not an expected effect of liquid iron preparation and should not be reassured as a desired effect. Choice D is incorrect as it does not directly address the client's concern about tooth staining.

4. A client with uterine cancer asks the nurse, 'Which is the most common type of cancer in women?' The nurse replies that it is breast cancer. Which type of cancer causes the most deaths in women?

Correct answer: B

Rationale: Lung cancer is the leading cause of cancer-related deaths in women, surpassing even breast cancer. While breast cancer is more common, it is often detected early enough for effective treatment. Lung cancer, on the other hand, tends to be diagnosed at later stages, leading to higher mortality rates. Brain cancer and colon and rectal cancer are not the leading causes of cancer-related deaths in women, making them incorrect choices.

5. After a laparoscopic cholecystectomy, what is the most important instruction the nurse should give the client regarding post-operative care at home?

Correct answer: C

Rationale: Monitoring the incision sites for signs of infection is crucial after a laparoscopic cholecystectomy. Infections can lead to serious complications if not detected early. While avoiding heavy lifting and following a low-fat diet are important aspects of recovery, monitoring for infection takes precedence as it directly impacts the client's immediate post-operative well-being. Therefore, option C is the correct answer as it addresses the most critical aspect of post-operative care.

Similar Questions

A new mother who is breastfeeding her newborn for the first time after delivery reports nipple pain when the baby sucks. Based on this client problem, which action should the PN take?
During a clinic visit for a sore throat, a client's basal metabolic panel reveals a serum potassium of 3.0 mEq/L. Which intervention should the PN recommend to the client based on this finding?
A client post-thoracotomy is complaining of severe pain with deep breathing and coughing. What should the nurse encourage the client to do to manage the pain and prevent respiratory complications?
An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units in the morning. Which finding should the PN document as evidence that the amount of insulin is inadequate?
A post-operative client develops a sudden onset of chest pain and dyspnea. The nurse suspects a pulmonary embolism (PE). What is the priority nursing action?

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