When caring for a client with a tracheostomy, the nurse should be aware of which of the following?
1. Suctioning a client's tracheostomy that is less than 48 hours old requires only clean technique.
2. The wound around the tracheostomy tube should be cleaned every 48 hours.
3. Care of a client's new tracheostomy is not generally delegated to a nursing assistant.
4. The gauze dressing should be cut to fit snugly around the tracheostomy tube during the dressing change.
ANS: 3
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The nurse explains that the birth weight of monozygotic twins is frequently below average. What is the most likely cause?
a. Inadequate space in the uterus b. Inadequate blood supply c. Inadequate maternal health d. Inadequate placental nutrition
After a large weight loss a patient tells the nurse, "There still is a fat person inside of me." This type of statement illustrates a flaw in what self-concept component?
a. Role performance b. Identity stressor c. Self-esteem d. Body image
You (the nurse) are reviewing the educational packet provided to a patient about tubal ligation. What is an important fact you should point out? Choose all that apply
a. "It is highly unlikely that you will become pregnant after the procedure." b. "This is an effective form of 100% permanent sterilization. You won't be able to get pregnant." c. "Sterilization offers some form of protection against sexually transmitted infec-tions (STIs)." d. "Sterilization offers no protection against STIs." e. "Your menstrual cycle will greatly increase after your sterilization."
The Joint Commission restricts the use of restraints to the least restrictive device necessary to prevent disruption of needed care. The order for restraints must include which of the following? (Select all that apply.)
a. Type b. Duration c. Purpose d. Location e. Size