Which nursing intervention would you use to prevent tracheal stenosis in a client after tracheostomy?
A. Securing the tube in a midline position
B. Assessing bilateral breath sounds every 2 hours
C. Changing the tracheostomy ties every 24 hours
D. Suctioning the tube with as small a catheter as possible
A
Tracheal stenosis, a narrowed tracheal lumen, is the result of scar tissue formation from irritation. Two methods of preventing this complication are to keep the tube from moving in the trachea and to maintain proper cuff pressure.
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Lithium toxicity is most likely with which of the following patients?
A. Elderly man with diarrhea from food poisoning B. Teenage girl on oral contraceptives C. 40-year-old man who smokes marijuana on the weekend D. All of the above are at high risk
The nurse is inspecting the tonsils for a client with a fever and sore throat. The nurse observes purulent exudate on the surface of the tonsils. What does this finding indicate to the nurse?
A) Filariasis B) Thrush C) An abscess D) Tonsillitis
Before beginning the health history interview, the nurse should perform all actions except:
a. Smile and ask the patient whether she has any special concerns. b. Speak in a relaxed manner with an even, nonjudgmental tone. c. Make the patient comfortable. d. Tell the patient her questions are irrelevant.
The nurse is caring for a client with otitis media and notes purulent drainage in the ear canal during the physical assessment. Which is the nurse's priority intervention?
a. Obtain a specimen of the drainage for culture. b. Irrigate the ear canal with sterile normal saline. c. Gently examine the client's ear with an otoscope. d. Place a cotton ball in the ear canal to ab-sorb the drainage.