a nurse is preparing to perform tracheostomy care for a client which of the following actions should the nurse take first
Logo

Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

1. A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: Suctioning the tracheostomy should be performed first to clear the airway of secretions and ensure proper oxygenation before proceeding with other care. This helps maintain a patent airway and prevent complications such as aspiration. Applying a sterile dressing, removing the inner cannula, or cleaning the stoma can follow after ensuring adequate airway clearance through suctioning.

2. A nurse is caring for a client who has deep vein thrombosis of the left lower extremity. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take when caring for a client with deep vein thrombosis is to withhold heparin IV infusion. Administering heparin is crucial in managing deep vein thrombosis by preventing further clot formation. Positioning the affected extremity higher than the heart (Choice A) promotes venous return and reduces swelling. Acetaminophen (Choice B) can be given for pain relief. Massaging the affected extremity (Choice C) is contraindicated as it can dislodge a clot, leading to serious complications.

3. A client with diabetes mellitus is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C. Eating snacks rich in carbohydrates is essential to manage hypoglycemia by raising blood sugar levels. Option A is incorrect as monitoring blood sugar once a week is not frequent enough for effective diabetes management. Option B is incorrect because exercising when blood sugar is low can worsen hypoglycemia. Option D is incorrect as it focuses on preventing high blood sugar levels, not managing low blood sugar.

4. A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction for the nurse to include is to advise the client to take their pulse before taking digoxin. This is important to monitor for bradycardia, a potential side effect of the medication. Option A is incorrect because digoxin is usually taken in the morning. Option C is unrelated to digoxin therapy, as high potassium foods are usually restricted in clients taking potassium-sparing diuretics. Option D is incorrect because digoxin should not be taken with antacids as they can affect its absorption.

5. A nurse is teaching a client who has a new prescription for captopril. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is D. Captopril is known to cause a persistent, dry cough as a common side effect. Instructing the client about this potential side effect is crucial for their awareness. Choices A and B are incorrect because captopril is usually taken on an empty stomach. Choice C is incorrect because captopril can lead to hyperkalemia, so potassium supplements may be necessary in some cases.

Similar Questions

A client at 14 weeks gestation reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make?
What is the primary nursing intervention for a patient experiencing hypoglycemia?
A client with a colostomy needs optimal skin integrity. What action should the nurse take to promote this?
Which electrolyte imbalance is most common in patients receiving furosemide?
A nurse is assessing a client who has diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?

Access More Features

ATI RN Basic
$69.99/ 30 days

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

ATI RN Premium
$149.99/ 90 days

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

Other Courses