Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing discharge teaching to the partner of a client who has a tracheostomy.
Which of the following information should the nurse include in the teaching
A. How to change the nondisposable tracheostomy tube daily.
is wrong because the nondisposable tracheostomy tube does not need to be changed daily. It can be changed every 1 to 3 months, depending on the type of tube.
B. How to operate the portable suction machine.
The nurse should include this information in the teaching because suctioning is often needed to keep the tracheostomy tube and opening free from extra mucus and secretions that come from the lungs and tissue around the stoma. Suctioning can help prevent the tube from becoming plugged and improve breathing.
C. How to change the tracheostomy dressing using clean technique
because the tracheostomy dressing should be changed using sterile technique, not clean technique, to prevent infection.
D. How to secure the tracheostomy tube with ties at the back of the neck
the tracheostomy tube should not be secured with ties at the back of the neck. The ties should be fastened at the front or side of the neck, and they should be snug but not too tight.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
The correct answer is choice B. How to operate the portable suction machine. The nurse should include this information in the teaching because suctioning is often needed to keep the tracheostomy tube and opening free from extra mucus and secretions that come from the lungs and tissue around the stoma. Suctioning can help prevent the tube from becoming plugged and improve breathing.
Choice A is wrong because the nondisposable tracheostomy tube does not need to be changed daily. It can be changed every 1 to 3 months, depending on the type of tube.
Choice C is wrong because the tracheostomy dressing should be changed using sterile technique, not clean technique, to prevent infection.
Choice D is wrong because the tracheostomy tube should not be secured with ties at the back of the neck. The ties should be fastened at the front or side of the neck, and they should be snug but not too tight.
Similar Questions
A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube.
Which of the following actions should the nurse plan to take?
A. Measure gastric residual volumes every 4 hr.
Measure gastric residual volumes every 4 hr. This is because continuous enteral feedings through an NG tube can increase the risk of aspiration, which is the inhalation of food or fluids into the lungs. Measuring gastric residual volumes (GRV) can help monitor the tolerance and absorption of the feedings and prevent overfeeding. GRV is the amount of fluid aspirated from the stomach via an enteral tube to check for gastric emptying. The normal range of GRV is less than 200 ml.
B. Advance the rate of the feeding every 2 hr.
because advancing the rate of the feeding every 2 hr can lead to overfeeding, abdominal distension, nausea, vomiting and diarrhea. The rate of the feeding should be adjusted according to the client’s nutritional needs and tolerance.
C. Maintain the head of the bed at a 20° angle.
because maintaining the head of the bed at a 20° angle is not enough to prevent aspiration. The head of the bed should be elevated at least 30° to 45° during and for at least one hour after feeding.
D. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication
wrong because flushing the NG tube with 30 mL 0.9% sodium chloride before and after medication is not related to continuous enteral feedings. This is a practice to prevent clogging of the tube and ensure proper delivery of medication. Flushing the tube with water before and after feeding is also recommended to maintain patency and hydration.
Full Explanation
The correct answer is choice A. Measure gastric residual volumes every 4 hr.
This is because continuous enteral feedings through an NG tube can increase the risk of aspiration, which is the inhalation of food or fluids into the lungs. Measuring gastric residual volumes (GRV) can help monitor the tolerance and absorption of the feedings and prevent overfeeding. GRV is the amount of fluid aspirated from the stomach via an enteral tube to check for gastric emptying. The normal range of GRV is less than 200 ml.
Choice B is wrong because advancing the rate of the feeding every 2 hr can lead to overfeeding, abdominal distension, nausea, vomiting and diarrhea.
The rate of the feeding should be adjusted according to the client’s nutritional needs and tolerance.
Choice C is wrong because maintaining the head of the bed at a 20° angle is not enough to prevent aspiration. The head of the bed should be elevated at least 30° to 45° during and for at least one hour after feeding.
Choice D is wrong because flushing the NG tube with 30 mL 0.9% sodium chloride before and after medication is not related to continuous enteral feedings. This is a practice to prevent clogging of the tube and ensure proper delivery of medication. Flushing the tube with water before and after feeding is also recommended to maintain patency and hydration.
A nurse is teaching a client who has rheumatoid arthritis about illness management.
Which of the following instructions should the nurse include in the teaching?
A. Apply cold packs directly on the skin of the affected joints.
because applying cold packs directly on the skin of the affected joints can cause vasoconstriction and increase inflammation. Cold therapy should be used with caution and with a barrier between the skin and the ice pack.
B. Administer biological response modifiers to prevent infection
wrong because biological response modifiers are not used to prevent infection, but to reduce inflammation and slow down joint damage in rheumatoid arthritis. These medications can actually increase the risk of infection by suppressing the immune system.
C. Take a hot shower in the morning to decrease stiffness.
Taking a hot shower in the morning can help decrease stiffness and improve joint mobility for people with rheumatoid arthritis. This is one of the self-management strategies that can reduce pain and disability.
D. Cluster physical activities during the day
because clustering physical activities during the day can cause fatigue and joint stress for people with rheumatoid arthritis.
Full Explanation
The correct answer is choice C. Taking a hot shower in the morning can help decrease stiffness and improve joint mobility for people with rheumatoid arthritis. This is one of the self-management strategies that can reduce pain and disability.
Choice A is wrong because applying cold packs directly on the skin of the affected joints can cause vasoconstriction and increase inflammation.
Cold therapy should be used with caution and with a barrier between the skin and the ice pack.
Choice B is wrong because biological response modifiers are not used to prevent infection, but to reduce inflammation and slow down joint damage in rheumatoid arthritis.
These medications can actually increase the risk of infection by suppressing the immune system.
Choice D is wrong because clustering physical activities during the day can cause fatigue and joint stress for people with rheumatoid arthritis.
It is better to pace activities throughout the day and take frequent breaks to rest the joints.
Normal ranges for rheumatoid arthritis are based on the disease activity score (DAS), which measures the number of swollen and tender joints, the level of inflammation in the blood, and the patient’s global assessment of health. A DAS below 2.6 indicates remission, a DAS between 2.6 and 3.2 indicates low disease activity, a DAS between 3.2 and 5.1 indicates moderate disease activity, and a DAS above 5.1 indicates high disease activity.
A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
A. Raise the side rails on both sides of the client’s bed during repositioning.
is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment. The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.
B. Reposition the client without the use of assistive devices.
wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client. The nurse should use assistive devices that are appropriate for the client’s condition and weight.
C. Discuss the client’s preferences for determining a repositioning schedule.
wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke. The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.
D. Evaluate the client’s ability to help with repositioning.
Correct! Evaluate the client’s ability to help with repositioning. This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort. The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.
Full Explanation
The correct answer is choice D. Evaluate the client’s ability to help with repositioning.
This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort.
The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.
Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.
The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.
Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.
The nurse should use assistive devices that are appropriate for the client’s condition and weight.
Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.
The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.
The nurse should also involve the client in the care plan and respect their preferences whenever possible.