what is the priority nursing intervention for a patient with a new tracheostomy
Logo

Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. What is the priority nursing intervention for a patient with a new tracheostomy?

Correct answer: A

Rationale: The correct answer is to suction the tracheostomy as needed to maintain a patent airway. After a tracheostomy procedure, the immediate concern is airway patency to prevent respiratory compromise. Suctioning helps clear secretions and maintains a clear airway, reducing the risk of respiratory distress. Monitoring the patient's oxygen saturation (choice B) is important but not the priority compared to ensuring a clear airway. Providing humidified air (choice C) and administering pain medication (choice D) are also essential aspects of care for a patient with a tracheostomy, but they are not the priority when immediate airway management is required.

2. A nurse is using the ecologic model for population health to develop interventions to address HIV in a community. Which of the following interventions should the nurse include to address financial factors affecting community health?

Correct answer: B

Rationale: The correct answer is B. Distributing condoms addresses financial barriers by providing access to essential protective measures in remote areas. Choice A focuses on education rather than direct intervention related to financial factors. Choice C involves advertising and not a direct intervention to address financial factors. Choice D pertains to education about HIV transmission rather than directly addressing financial barriers affecting community health.

3. A nurse on a rehabilitation unit is creating a plan of care for a newly admitted client who has difficulty swallowing following a stroke. Which of the following inter-professional team members should the nurse anticipate consulting regarding the client's condition?

Correct answer: A

Rationale: The correct answer is A, Speech-language pathologist. A speech-language pathologist specializes in evaluating and treating swallowing difficulties, known as dysphagia, which commonly occurs following a stroke. They are experts in developing strategies to help individuals improve their ability to swallow safely. Occupational therapists (B) focus on helping individuals regain independence in activities of daily living, not specifically addressing swallowing concerns. Dietitians (C) primarily work on developing appropriate nutrition plans but may not directly address swallowing issues. Pharmacy technicians (D) assist pharmacists in dispensing medications and are not directly involved in managing swallowing difficulties.

4. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing an acute hemolytic reaction?

Correct answer: C

Rationale: Chills and fever are classic signs of an acute hemolytic reaction, where the body is reacting to the transfused blood. This reaction can be life-threatening and requires immediate intervention. Low back pain, distended neck veins, and headache are not typical signs of an acute hemolytic reaction. Low back pain may be associated with kidney issues, distended neck veins with fluid overload or heart failure, and headache with various causes such as stress, dehydration, or migraines.

5. A nurse is teaching a client about levothyroxine for primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?

Correct answer: D

Rationale: Tremors, nervousness, and insomnia indicate that the dose may be too high, requiring a dose adjustment.

Similar Questions

A nurse in a clinic is caring for a client who has a urinary tract infection (UTI). Which of the following prescriptions should the nurse verify with a provider?
A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse include?
A client has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have?
A healthcare professional is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the healthcare professional place at the client's bedside?
Which of the following is an adverse effect of Lithium Carbonate that requires client education?

Access More Features

ATI RN Basic
$69.99/ 30 days

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

ATI RN Premium
$149.99/ 90 days

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

Other Courses