The client coughs out the tracheostomy tube. Which does the nurse implement?
1. Ventilate the client manually.
2. Insert a new tracheostomy tube.
3. Open the stoma with a fingertip.
4. Speak to the client's provider.
2
2. The nurse maintains an obturator at the client's bedside for accidental extubation. If the tracheostomy tube comes out, the nurse inserts the obturator into the tube and inserts it into the stoma. The obturator is a tapered tip for the tracheostomy tube to facilitate insertion.
1. Extubation results in the client losing the airway; the client needs an airway before ventilation can begin.
3. The nurse avoids using a fingertip to open the stoma because it occludes the air-way; the client needs a patent tube for an airway for air passage.
4. The nurse's priority is the client's airway because the nurse potentially wastes pre-cious time contacting the provider. The nurse is required and prepared to implement emergency measures for accidental extubation to restore the airway to provide oxy-genation and ventilation for client survival.
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The nurse is reviewing data collected for a patient's health history. Which factor should the nurse identify as increasing the patient's risk of developing type 2 diabetes mellitus?
1. body mass index of 23 kg/m2 2. blood pressure of 120/70 3. physical inactivity 4. low waist-to-hip ratio
Which of the following situations is an example of the nurse using empathy?
a. Setting up a rehabilitation placement for a client addicted to heroin b. Sitting quietly and holding a client's hand while she cries following the news that she has inoperable cancer c. Giving a bed bath to a client who suffers from a cerebral vascular accident (CVA) d. Telling a client all about the fun night at one of the local clubs
A patient in labor has just received IV sedation. What must the nurse tell the patient to do?
A) Ambulate only with assistance from the nurse or caregiver B) Ambulate within 15 minutes to prevent spinal headache C) Sit on the edge of the bed and dangle the feet before ambulating D) Remain in bed for at least 30 minutes
Which comment by the nurse would be most effective when using an empowerment model of intervention with an individual who has been abused?
a. "You have left your spouse many times only to return. Please tell me how you view this last time as being different from all the times you left before.". b. "Last time we talked, you thought your children would miss their father, but you now think they seem happier and almost relieved by your separation.". c. "So you're having doubts and want to return to your husband even though you know that he broke your arm and caused your miscarriage?" d. "I support you returning to your spouse until you finally decide you have suffered enough.'"