mr landon is to have a tracheostomy performed what is the top nursing priority
Logo

Nursing Elites

HESI RN

HESI Fundamentals Practice Exam

1. Prior to Mr. Landon undergoing a tracheostomy, what is the top nursing priority?

Correct answer: B

Rationale: Before Mr. Landon undergoes a tracheostomy, the top nursing priority is to establish a means of communication. This is essential to ensure that Mr. Landon can effectively communicate his needs during and after the procedure. Shaving the neck (Choice A) may be necessary for the tracheostomy but is not the top priority. Inserting a Foley catheter (Choice C) and starting an IV (Choice D) are important nursing interventions but are not the priority before a tracheostomy procedure, where communication is key for patient safety and comfort.

2. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?

Correct answer: A

Rationale: Administering regular insulin IV (A) is the initial intervention for a client with diabetic ketoacidosis (DKA) to rapidly reduce blood glucose levels. This is vital in reversing the ketosis and acidosis seen in DKA. Administering IV fluids (B) helps to correct dehydration and electrolyte imbalances. Administering sodium bicarbonate (C) and furosemide (D) may be necessary depending on the client's condition, but insulin administration takes precedence in the management of DKA.

3. The healthcare provider is assessing a client with a diagnosis of pneumonia. Which assessment finding is most concerning?

Correct answer: D

Rationale: A respiratory rate of 28 breaths per minute (D) is most concerning because it indicates respiratory distress and requires immediate intervention. While coarse crackles (A), fever (B), and productive cough (C) are common findings in pneumonia, a high respiratory rate signifies a more severe condition that needs prompt attention to prevent respiratory failure. Monitoring the respiratory rate is crucial in assessing the severity of respiratory distress in pneumonia, as it can rapidly progress to respiratory failure if not managed promptly.

4. The client was placed in restraints due to confusion while hospitalized. The family removes the restraints in the client's presence. After the family leaves, what should the nurse do first?

Correct answer: B

Rationale: In this scenario, the nurse's initial action should be to reassess the client to determine if restraints are still necessary following their removal by the family. This reassessment is crucial to evaluate the client's current condition and the need for restraints before considering reapplication. By reassessing first, the nurse ensures that the client's safety is maintained while respecting their autonomy. While documentation and monitoring are important, reassessment takes priority to provide individualized and appropriate care to the client. Contacting the healthcare provider for a new order should occur after reassessment if restraints are deemed necessary.

5. The client is receiving discharge teaching for a new diagnosis of asthma. Which statement by the client indicates a need for further teaching?

Correct answer: B

Rationale: The statement 'I should avoid using my inhaler unless I am having an asthma attack' (B) indicates a need for further teaching. It is important for clients to use their inhaler as prescribed, which may include regular use to prevent asthma attacks. Choice A is correct because using the inhaler when feeling short of breath can help manage asthma symptoms. Choice C is also correct as using the inhaler before exercise can prevent exercise-induced symptoms. Choice D is correct as rinsing the mouth after using the inhaler helps prevent oral thrush, a potential side effect of inhaled corticosteroids. Therefore, option B is the most concerning statement that needs clarification.

Similar Questions

After insertion of the indwelling catheter, how should the nurse position the drainage container?
The nursing staff in the cardiovascular intensive care unit is creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy?
The healthcare provider is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the healthcare provider take next?
After surgery, a patient has decreased cardiac output. What is a likely observation by the nurse?
A male healthcare provider is assigned to care for a female Muslim client. When the provider offers to bathe the client, the client requests that a female healthcare provider perform this task. How should the male healthcare provider respond?

Access More Features

HESI RN Basic
$69.99/ 30 days

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

HESI RN Premium
$149.99/ 90 days

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

Other Courses