A patient with a tracheostomy tube has thick, tenacious mucus that is difficult to remove. The nurse should choose which technique to suction the airway?
a. Normal saline instillation (NSI) before suctioning
b. Dry suctioning 1 time followed by NSI with suctioning 2 more times
c. Dry suctioning as long as the heart rate is above 60 beats/min
d. Dry suctioning
D
Normal saline instillation (NSI) into artificial airways is no longer recommended as standard practice. Clinical studies show that suctioning with or without NSI produces similar amounts of secretions and significant decreases in oxygen saturation. Potential side effects include increases in heart rate for 4 to 5 minutes after suctioning using NSI as opposed to dry suctioning. NSI has the potential to increase ventilator-associated pneumonia because bacteria from the upper airway can be dislodged to the lower airway.
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A 4-year-old has been diagnosed with seizure disorder, and the health care provider suspects the client may also be autistic. What should the nurse have the parents observe for in this client?
Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Does the child make eye contact? 2. Does the child watch television? 3. Does the child have friends at daycare? 4. Can the child entertain self for a period of time? 5. Is the child's language development within normal expectations?
A patient on levodopa (Dopar) for Parkinson's disease comes to the emergency department complaining of a severe headache. The vital signs are: temperature 98.8° F, pulse 92/minute, blood pressure 202/107, and respirations 18/minute
A nurse should be most concerned if which of the following drugs is on the patient's current list? a. Carbidopa b. Phenelzine (Nardil) c. Citalopram (Celexa) d. Amitriptyline
A middle-aged client is having a physical examination and is worried about cancer risk. Which question is most important for the nurse to ask?
a. "How much time do you spend in the sun?" b. "How many servings of fruits and vegeta-bles do you eat every day?" c. "How often do you eat processed meats like bologna?" d. "Do you smoke cigarettes or have you ev-er used tobacco products?"
Based on school-aged cognitive development, which teaching technique could you anticipate as being received the best?
A) Using containers of water to demonstrate how hemorrhage leads to decreased body fluid B) Asking children to conceptualize the effect of falling blood pressure C) Asking children to think through "what if" situations and blood pressure D) Explaining elevated and decreased blood pressure as a concept