a nurse is preparing to perform tracheostomy care for a client which of the following actions should the nurse take first
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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 is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: A temperature of 38.8°C (101.8°F) is above the normal range and may indicate infection, which should be reported. Elevated temperature postoperatively can be a sign of infection, especially in the early postoperative period. Serosanguineous drainage on the surgical dressing is expected in the early postoperative period. A heart rate of 88/min and a blood pressure of 118/76 mm Hg are within normal ranges and do not necessarily indicate a complication postoperatively.

3. What is the correct method of administering insulin to a patient with diabetes?

Correct answer: A

Rationale: The correct method of administering insulin to a patient with diabetes is to administer it subcutaneously. Insulin is typically injected into the fatty tissue just below the skin, allowing for a slow and consistent absorption into the bloodstream. Administering insulin intramuscularly (Choice B) is not recommended as it can lead to unpredictable absorption rates and potential complications. Administering insulin intravenously (Choice C) is only done in specific medical settings and not for routine diabetes management. Administering insulin orally (Choice D) is ineffective as the stomach acid would break down the insulin before it can be absorbed.

4. How should a healthcare professional monitor for infection in a patient with a central line?

Correct answer: A

Rationale: Correct answer: A. Checking the central line dressing daily is crucial to monitor for signs of infection around the insertion site. This practice helps in early detection of any changes such as redness, swelling, or discharge, which are indicators of a potential infection. Monitoring for signs of redness (choice B) is limited as redness alone may not always indicate an infection; other symptoms like discharge and tenderness should also be observed. Checking for abnormal breath sounds (choice C) is not directly related to monitoring central line infections. Monitoring temperature (choice D) is important for detecting systemic signs of infection but may not specifically indicate an infection related to the central line site.

5. A client with a new diagnosis of diabetes mellitus is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C because checking blood sugar levels every morning before breakfast is a crucial aspect of managing diabetes effectively. This practice helps individuals monitor their blood sugar levels regularly and adjust their treatment plan as needed. Option A is incorrect as consuming a bedtime snack based on blood sugar levels alone may not be an appropriate approach to managing diabetes. Option B is incorrect as relying on more sugar-free candy does not address the overall dietary management of blood sugar levels. Option D is incorrect as avoiding physical activity when blood sugar is below 100 mg/dL can hinder diabetes management, as exercise is generally beneficial for controlling blood sugar levels.

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