The nurse is participating in the planning of care for a patient with a newly placed tracheostomy. Which interventions should the nurse identify as a priority for this patient? (Select all that apply.)
a. Restrict fluids.
b. Turn and reposition every shift.
c. Assess lung sounds every 4 hours.
d. Suction using sterile technique as needed.
e. Perform tracheostomy care according to policy.
ANS: C, D, E
When caring for a patient with a tracheostomy, lung sounds should be assessed every 4 hours, suctioning should be performed as needed using sterile technique, and tracheostomy care should be performed according to agency policy. A. Fluids should be encouraged to thin secretions. B. The patient should be turned and repositioned every 2 hours to prevent pooling of respiratory secretions.
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The following information is recorded in the health history: “The patient has had abdominal pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7 to 9 on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the mid-epigastric area.” Which of these categories does it belong to?
A) Chief complaint B) Present illness C) Personal and social history D) Review of systems
Sociological needs are met by
A. praise from other people. B. communication and personal expression. C. one's personal sense of self-worth. D. activity, rest, and sleep.
Identify the statement that describes a population
1. Trauma clients hospitalized in an intensive care unit during January 2010 2. Four hundred nurses selected from a membership list of American Nurses' Association (ANA) members 3. Members of families of clients undergoing surgery, sitting in the waiting room of St. Francis Hospital 4. Members of a cult identified by other members of the same cult
Which of the following statements made by a nursing student indicates the need for further education about family-focused nursing?
1. "When family members are not well-supported during hospitalization, patients are often readmitted." 2. "Families that are well-supported by nurses during hospitalization are more satisfied with their care." 3. "While the individual patient is the focus during early hospitalization, the family should be included when things stabilize." 4. "When nurses exclude family members from patient care, suffering may be magnified."