what are the nursing interventions for a patient with a tracheostomy

ATI LPN

ATI PN Comprehensive Predictor

1. What are the key nursing interventions for a patient with a tracheostomy?

A. Maintain a patent airway and monitor for infection
B. Suction airway secretions and provide humidified oxygen
C. Educate patient on self-care and tracheostomy cleaning
D. Change tracheostomy ties daily

Correct answer: A

Rationale: The correct answer is to maintain a patent airway and monitor for infection. These are crucial nursing interventions for patients with tracheostomies to ensure adequate oxygenation and prevent complications. Suctioning airway secretions and providing humidified oxygen can be part of the care plan but are not as essential as maintaining a patent airway. Educating the patient on self-care and tracheostomy cleaning is important for long-term management but is not as immediate as ensuring a patent airway and monitoring for infection. Changing tracheostomy ties daily is a specific task related to tracheostomy care but is not as critical as ensuring the airway is clear and infection-free.

2. A client is concerned about extreme fatigue after an acute myocardial infarction. What is the best strategy the nurse can suggest to promote independence in self-care?

A. Encourage the client to rest and let the healthcare team take over self-care tasks
B. Instruct the client to gradually resume self-care tasks, with rest periods
C. Assign assistive personnel to complete self-care tasks for the client
D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: The best strategy to promote independence in self-care for a client concerned about extreme fatigue after an acute myocardial infarction is to instruct the client to gradually resume self-care tasks, with rest periods. This approach allows the client to regain independence without overexerting. Choice A is incorrect because encouraging the client to rest completely and letting the healthcare team take over self-care tasks may hinder independence. Choice C is incorrect as assigning assistive personnel to complete self-care tasks does not promote the client's independence. Choice D is not the best option as the primary focus should be on empowering the client to perform self-care tasks independently.

3. A client receiving chemotherapy is experiencing fatigue. Which intervention should the nurse implement to manage the client's fatigue?

A. Encourage the client to take short naps during the day
B. Instruct the client to remain on bedrest
C. Provide the client with a high-calorie diet
D. Encourage the client to increase activity levels

Correct answer: A

Rationale: The correct intervention to manage fatigue in a client receiving chemotherapy is to encourage the client to take short naps during the day. Fatigue is a common side effect of chemotherapy, and allowing the client to rest can help combat this symptom. Instructing the client to remain on bedrest (Choice B) is not recommended as it may lead to deconditioning and worsen fatigue. Providing a high-calorie diet (Choice C) may be beneficial for overall nutrition but does not directly address fatigue. Encouraging the client to increase activity levels (Choice D) may exacerbate fatigue instead of alleviating it.

4. What are the key interventions for managing a patient with asthma?

A. Administer bronchodilators and monitor oxygen levels
B. Encourage deep breathing exercises
C. Provide corticosteroids and monitor for respiratory distress
D. Provide antihistamines and monitor blood pressure

Correct answer: A

Rationale: The correct answer is A: Administer bronchodilators and monitor oxygen levels. Asthma management involves using bronchodilators to help open the airways and improve breathing. Monitoring oxygen levels is essential to ensure the patient is getting enough oxygen. Choice B, encouraging deep breathing exercises, can be helpful for some respiratory conditions but is not a key intervention for managing an acute asthma attack. Choice C, providing corticosteroids and monitoring for respiratory distress, is important for long-term asthma management and severe exacerbations but is not the immediate key intervention during an acute attack. Choice D, providing antihistamines and monitoring blood pressure, is not typically indicated for asthma management as asthma is primarily an airway disease, not a histamine-mediated condition.

5. A nurse is reviewing the plan of care for a client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse include?

A. Apply heat to the affected area
B. Place the client in a prone position
C. Turn and reposition the client every 2 hours
D. Provide the client with a bedpan every 4 hours

Correct answer: C

Rationale: The correct intervention for a client at risk for pressure ulcers is to turn and reposition the client every 2 hours. This helps relieve pressure on bony prominences, improving circulation and reducing the risk of pressure ulcer development. Applying heat to the affected area (Choice A) can increase the risk of skin breakdown. Placing the client in a prone position (Choice B) can also increase pressure on certain areas, leading to pressure ulcers. Providing the client with a bedpan every 4 hours (Choice D) is not directly related to preventing pressure ulcers.