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. What are the potential complications of a patient receiving total parenteral nutrition (TPN)?

A. Infection and electrolyte imbalance
B. Hyperglycemia and sepsis
C. Kidney failure and hypovolemia
D. Fluid overload and liver damage

Correct answer: A

Rationale: Infection and electrolyte imbalance are common complications of TPN. Infection can occur due to the invasive nature of TPN, which provides a direct route for pathogens. Electrolyte imbalances can arise from the composition of the TPN solution or improper monitoring. Hyperglycemia and sepsis (Choice B) are potential complications but are not as directly associated with TPN as infection and electrolyte imbalance. Kidney failure and hypovolemia (Choice C) are less common complications of TPN. Fluid overload and liver damage (Choice D) are potential complications but are not as frequently observed as infection and electrolyte imbalance.

3. How should a healthcare provider assess and manage a patient with anemia?

A. Monitor hemoglobin levels and provide iron supplements
B. Administer B12 injections
C. Monitor for signs of infection and administer folic acid
D. Administer oxygen therapy

Correct answer: A

Rationale: Corrected Question: To assess and manage a patient with anemia, monitoring hemoglobin levels and providing iron supplements are crucial. Anemia is commonly caused by iron deficiency, making iron supplementation a cornerstone of treatment. B12 injections (Choice B) are more relevant for treating megaloblastic anemia, not the typical iron-deficiency anemia. Monitoring for signs of infection and administering folic acid (Choice C) are important in specific types of anemia like megaloblastic anemia, but not the first-line approach for anemia management. Administering oxygen therapy (Choice D) is not the primary intervention for anemia unless severe hypoxemia is present, which is not typically seen in anemia.

4. A nurse is caring for a client who is scheduled for surgery in the morning. The nurse learns that the client has decided not to have surgery even though they have already signed the informed consent form. Which of the following actions should the nurse take?

A. Ignore the client's decision and proceed
B. Report the situation to the provider
C. Ask the family to convince the client
D. Reassess the need for surgery with the client

Correct answer: B

Rationale: The correct action for the nurse to take is to report the client's decision to the provider who obtained informed consent. This ensures that the provider is informed of the client's change in decision and can discuss the situation further with the client. Choice A is incorrect as ignoring the client's decision is not appropriate and goes against the principles of patient autonomy. Choice C is incorrect because involving the family in convincing the client can be coercive and may not respect the client's autonomy. Choice D is incorrect because the nurse should not re-sign the informed consent form without the client's consent and a discussion with the provider.

5. What are the nursing considerations when administering blood products?

A. Monitor vital signs and check for allergic reactions
B. Verify blood type and compatibility before transfusion
C. Monitor for signs of infection and sepsis
D. Ensure consent is signed and prepare for possible reaction

Correct answer: A

Rationale: The correct answer is A: Monitor vital signs and check for allergic reactions. When administering blood products, monitoring vital signs such as blood pressure, heart rate, and temperature is crucial to detect any adverse reactions promptly. Checking for allergic reactions, such as hives, itching, or difficulty breathing, is essential to ensure patient safety. Choice B is incorrect because verifying blood type and compatibility is typically done by the laboratory before the blood is issued for transfusion. Choice C is not a direct nursing consideration during the administration of blood products. While monitoring for signs of infection and sepsis is important in general patient care, it is not specific to blood transfusions. Choice D is also incorrect as ensuring consent is signed and preparing for possible reactions are important but do not directly relate to the immediate nursing considerations during blood product administration.