a nurse is providing tracheostomy care for a client which of the following actions should the nurse take
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Nursing Elites

ATI LPN

LPN Fundamentals of Nursing

1. During tracheostomy care, what action should a healthcare professional take?

Correct answer: D

Rationale: Changing tracheostomy ties if they are wet is essential to prevent infection and maintain skin integrity. Wet ties can harbor bacteria, increasing the risk of skin breakdown and other complications. Regularly changing wet ties promotes cleanliness, reduces the likelihood of complications, and ensures optimal care for the client with a tracheostomy.

2. While assessing a client with fluid volume deficit, which of the following findings should the nurse expect?

Correct answer: C

Rationale: Dry mucous membranes are a classic clinical manifestation of fluid volume deficit. Dehydration leads to reduced fluid intake or excessive fluid loss, resulting in decreased moisture in the mucous membranes. Bradycardia, increased skin turgor, and hypertension are not typically associated with fluid volume deficit. Bradycardia is more commonly seen in conditions like hypothyroidism or increased intracranial pressure. Increased skin turgor is a sign of dehydration, not deficit. Hypertension is not a typical finding in fluid volume deficit.

3. A client with ulcerative colitis is receiving dietary management education from a healthcare provider. Which statement by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because reducing dairy product intake can help manage symptoms of ulcerative colitis. Dairy products can exacerbate symptoms in some individuals due to their lactose content and may need to be limited or avoided based on individual tolerance levels. Choice A is incorrect because increasing dairy products can worsen symptoms for some ulcerative colitis patients. Choice C is incorrect as while high-fiber foods are generally beneficial, they may exacerbate symptoms during a flare-up. Choice D is also incorrect as while reducing high-fat foods can be beneficial, dairy products are a more specific concern for ulcerative colitis.

4. In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?

Correct answer: B

Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.

5. A client has tuberculosis, and the nurse is planning care. Which of the following isolation precautions should the nurse implement?

Correct answer: C

Rationale: The correct answer is C: Airborne. Tuberculosis is transmitted through the air, making it an airborne disease. Airborne precautions are crucial to prevent the spread of tuberculosis to others. These precautions include placing the client in a negative pressure room, wearing an N95 respirator mask, and ensuring proper ventilation to minimize the risk of transmission to healthcare workers and other clients. Choice A, Protective environment, is used for clients with compromised immune systems. Choice B, Contact precautions, are used for diseases spread by direct or indirect contact. Choice D, Droplet precautions, are for diseases transmitted through respiratory droplets, like influenza or pertussis.

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