a nurse is precepting a newly licensed nurse who is preparing to help a client perform tracheostomy care the nurse should intervene if the equipment t
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HESI LPN

Fundamentals of Nursing HESI

1. A nurse is precepting a newly licensed nurse who is preparing to help a client perform tracheostomy care. The nurse should intervene if the equipment the preceptee gathered included:

Correct answer: A

Rationale: The correct answer is A: Cotton balls. Cotton balls are not suitable for tracheostomy care due to the risk of lint and contamination. When performing tracheostomy care, sterile supplies such as sterile gloves, a suction catheter, and tracheostomy tubes are essential. Sterile gloves are needed to maintain asepsis, a suction catheter is necessary for airway clearance, and tracheostomy tubes are crucial for maintaining a patent airway. Cotton balls should be avoided to prevent introducing lint or fibers into the tracheostomy site, which can lead to infection or airway obstruction.

2. Twenty minutes after starting a heat application, the client mentions that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN?

Correct answer: D

Rationale: Choice D is the correct response. The body's receptors adapt to the heat over time, which can explain why the client no longer perceives the warmth from the heating pad. This phenomenon is known as thermal adaptation. Choices A, B, and C are incorrect. Choice A is inaccurate because the client not feeling the warmth does not necessarily mean they have derived the maximum benefit. Choice B incorrectly states that blood vessels dilating remove heat, which is not accurate. Choice C suggests increasing the temperature when the pad no longer feels warm, which could potentially lead to burns or discomfort for the client.

3. A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report?

Correct answer: D

Rationale: Information about transmission-based precautions is essential for infection control and continuity of care.

4. To minimize the side effects of vincristine (Oncovin) that a client is receiving, what does the LPN/LVN expect the dietary plan to include?

Correct answer: C

Rationale: The correct answer is to include a diet high in fluids to help minimize the side effects of vincristine. High fluid intake is important in managing potential side effects such as constipation, which is a common issue associated with vincristine therapy. Options A, B, and D are incorrect. A diet low in fat or high in iron is not specifically indicated for managing vincristine side effects. Additionally, a diet low in residue is not directly related to addressing vincristine side effects.

5. A client has a closed wound drainage system. Which of the following actions should the nurse take?

Correct answer: D

Rationale: In a closed wound drainage system, it is essential to maintain the drain in a dependent position to allow for proper drainage. Gravity aids in the flow of drainage, preventing fluid backflow or pooling. Avoiding pressing the container down to create a vacuum (Choice A) is crucial as it can lead to complications in the system. Wearing sterile gloves (Choice B) is important for infection control when handling the drainage system. Resetting the container with the drainage port closed (Choice C) is incorrect as it can cause spillage and contamination of the surrounding area.

Similar Questions

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A client who is terminally ill has a family member who is coping effectively with the situation. Which of the following statements should the nurse identify as an indication of effective coping?
Following surgery on the neck, the client asks the LPN why the head of the bed is up so high. The LPN should tell the client that the high-Fowler position is preferred for what reason?
Which client statement from the assessment data is likely to explain their noncompliance with propranolol hydrochloride (Inderal)?
A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain medication is not an option for managing pain. Which of the following is an appropriate response by the nurse?

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