the nurse is caring for a client with a tracheostomy which action should the nurse take to prevent tracheal tissue damage
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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. In a client with liver cirrhosis experiencing confusion and disorientation, what condition is most likely causing these symptoms?

Correct answer: A

Rationale: Hepatic encephalopathy is the most likely condition causing confusion and disorientation in a client with liver cirrhosis. This condition is a common complication of liver cirrhosis and is characterized by cognitive impairment due to elevated ammonia levels in the blood. The build-up of ammonia affects brain function, leading to symptoms such as confusion, disorientation, and altered consciousness. Hypoglycemia (choice B) may present with confusion but is less likely in a client with liver cirrhosis without a history of diabetes or insulin use. Electrolyte imbalance (choice C) and dehydration (choice D) can contribute to confusion but are not the primary causes in a client with liver cirrhosis experiencing these symptoms.

3. A patient with asthma is prescribed a corticosteroid inhaler. What is the most important instruction to give to the patient?

Correct answer: B

Rationale: The most important instruction to give to a patient using a corticosteroid inhaler is to rinse the mouth after each use. This is crucial to prevent the development of oral thrush, a common side effect of corticosteroid inhalers. Failure to rinse the mouth can lead to the overgrowth of yeast in the mouth, causing oral thrush, which can be uncomfortable and require additional treatment. Therefore, reminding patients to rinse their mouth after using the inhaler is essential in preventing this potential complication. Choices A, C, and D are incorrect. Using the inhaler only during asthma attacks may lead to uncontrolled asthma symptoms. Taking a double dose without healthcare provider instruction can result in overdose or side effects. Avoiding a spacer with the inhaler can reduce the effectiveness of delivering the medication to the lungs.

4. Why is a low-protein diet recommended for a patient with renal failure?

Correct answer: B

Rationale: A low-protein diet is crucial for patients with renal failure to reduce the generation of nitrogenous waste products like urea and creatinine, which the compromised kidneys struggle to eliminate effectively. By limiting protein intake, the production of these waste products is decreased, lessening the burden on the kidneys and helping to manage the progression of renal failure. Choices A, C, and D are incorrect because a low-protein diet primarily aims to reduce the workload on the kidneys by decreasing the production of nitrogenous waste, not to prevent fluid overload, maintain electrolyte balance, or prevent hyperglycemia.

5. A client with osteoporosis is being discharged home. Which instruction should the nurse include in the discharge teaching?

Correct answer: B

Rationale: Taking calcium supplements with meals is a crucial instruction for a client with osteoporosis. Calcium absorption is enhanced when taken with food, and proper calcium intake is essential for managing osteoporosis effectively by promoting bone health and density. Avoiding weight-bearing exercises (Choice A) is incorrect because these exercises help improve bone strength. Limiting vitamin D intake (Choice C) is also incorrect as vitamin D is necessary for calcium absorption. Increasing caffeine intake (Choice D) is not recommended as caffeine can interfere with calcium absorption.

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