the nurse is caring for a client with a tracheostomy which action should the nurse take to prevent tracheal tissue damage
Logo

Nursing Elites

ATI LPN

ATI PN Adult Medical Surgical 2019

1. What action should the nurse take to prevent tracheal tissue damage in a client with a tracheostomy?

Correct answer: C

Rationale: To prevent tracheal tissue damage in a client with a tracheostomy, the nurse should use the minimal leak technique when inflating the cuff. This method helps avoid excessive pressure on the tracheal tissue, thereby reducing the risk of damage. Choice A is incorrect because securing the tracheostomy ties too tightly can cause pressure and tissue damage. Choice B is incorrect as changing the tracheostomy tube daily is not necessary unless there is a specific clinical indication. Choice D is incorrect as cleaning the stoma with hydrogen peroxide can irritate the skin and mucous membranes, potentially leading to damage.

2. A 34-year-old woman presents with intermittent abdominal pain, bloating, and diarrhea. She notes that her symptoms improve with fasting. She has a history of iron deficiency anemia. What is the most likely diagnosis?

Correct answer: B

Rationale: The patient's symptoms of intermittent abdominal pain, bloating, and diarrhea that improve with fasting, along with a history of iron deficiency anemia, are highly suggestive of celiac disease. In celiac disease, gluten ingestion leads to mucosal damage in the small intestine, causing malabsorption of nutrients like iron, leading to anemia. The improvement of symptoms with fasting can be explained by the temporary avoidance of gluten-containing foods. Irritable bowel syndrome typically does not improve with fasting. Lactose intolerance usually presents with symptoms after dairy consumption, not with fasting. Crohn's disease typically presents with more chronic symptoms and is not commonly associated with improvement on fasting.

3. A 40-year-old woman presents with fatigue, polyuria, and polydipsia. Laboratory tests reveal hyperglycemia and ketonuria. What is the most likely diagnosis?

Correct answer: A

Rationale: The combination of symptoms including fatigue, polyuria, polydipsia, along with laboratory findings of hyperglycemia and ketonuria strongly suggest type 1 diabetes mellitus. In type 1 diabetes mellitus, there is a deficiency of insulin leading to high blood sugar levels (hyperglycemia) and the breakdown of fats producing ketones, causing ketonuria. Type 2 diabetes mellitus typically presents differently and is more common in older individuals. Diabetes insipidus is characterized by excessive thirst and urination due to a deficiency of antidiuretic hormone, distinct from the provided clinical scenario. Hyperthyroidism may present with some overlapping symptoms like fatigue, but it does not account for the specific laboratory findings of hyperglycemia and ketonuria seen in this case.

4. The client has acute kidney injury (AKI). Which assessment finding requires immediate intervention?

Correct answer: B

Rationale: An elevated serum potassium level of 6.2 mEq/L in a client with AKI can lead to life-threatening cardiac arrhythmias, necessitating immediate intervention. Hyperkalemia is a serious complication in AKI as impaired kidney function can result in the accumulation of potassium in the blood, posing a risk of cardiac arrest. Prompt treatment to lower potassium levels is crucial to prevent cardiac complications in this situation.

5. A client receiving total parenteral nutrition (TPN) through a central line suddenly develops dyspnea, chest pain, and a drop in blood pressure. What should the nurse do first?

Correct answer: C

Rationale: Placing the client in Trendelenburg position should be the initial action as it can help manage a suspected air embolism, a potential complication of TPN administration. This position helps trap air in the apex of the atrium, reducing the risk of air reaching the pulmonary circulation and causing further harm. Once the client is in a safe position, further actions such as stopping the TPN infusion, notifying the healthcare provider, and administering oxygen can be taken as appropriate.

Similar Questions

A client with type 1 diabetes mellitus is admitted with hyperglycemia. Which laboratory result requires the most immediate intervention?
The healthcare provider in the outpatient clinic has obtained health histories for these new patients. Which patient may need referral for genetic testing?
The sister of a patient diagnosed with BRCA gene-related breast cancer asks the nurse, 'Do you think I should be tested for the gene?' Which response by the nurse is most appropriate?
A patient with tuberculosis is started on rifampin. What advice should the nurse provide?
A 68-year-old man with a history of diabetes, hypertension, and coronary artery disease (s/p coronary artery bypass graft two years ago) presents to the emergency room with fevers and left-sided abdominal pain. His physical examination reveals a temperature of 101.5°F, pulse 96, and blood pressure of 135/80. His abdomen is soft with moderate left lower quadrant tenderness. There is no rebound or guarding. Bowel sounds are present. A CT scan is done which reveals inflammation around an area of the left colon. The next step in his workup/management should be

Access More Features

ATI LPN Basic
$69.99/ 30 days

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

ATI LPN Premium
$149.99/ 90 days

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

Other Courses