When a nurse is replacing a client's tracheostomy ties, which of these steps is correct?
a. Hold the neck plate firmly with one hand while untying and removing soiled tapes.
b. Remove soiled tapes, cleanse the neck plate, and replace with clean tapes.
c. Suction the tracheostomy, perform tracheostomy cleaning, cut the soiled tapes, and replace with clean tapes.
d. Sedate the client, remove soiled tapes, perform tracheostomy cleaning, and apply clean tapes.
A
When replacing tracheostomy ties, hold the neck plate firmly with one hand while untying and removing soiled tapes. This prevents accidental removal of the inner cannula.
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During a home visit and assessment of an infant and new mother, the nurse determines that the infant looks healthy
The mother asks several questions and listens attentively. One question she asks is whether the nurse is going to visit her again. Which response would be most appropriate? A) "Your baby looks healthy. You should not have any further questions." B) "The agency limits the number of visits I can make; I will let you know." C) "I plan to visit again. What would you like to accomplish at the next visit." D) "I can come weekly for the next 16 weeks, and then a staff nurse will visit."
The nurse assesses that the client has torticollis and that this may adversely influence the client's mobility. This individual has a(n):
1. Exaggeration of the lumbar spine curvature 2. Increased convexity of the thoracic spine 3. Abnormal anteroposterior and lateral curvature of the spine 4. Contracture of the sternocleidomastoid muscle with a head incline
A hematology unit is staffed by RNs, LPNs/LVNs, and unlicensed assistive personnel (UAP). When the nurse manager is reviewing documentation of staff members, which entry indicates that the staff member needs education about his or her appropriate level of responsibility and client care?
A. "Abdominal pain relieved by morphine 4 mg IV; client resting comfortably and denies problems. B.C., RN" B. "Ambulated in hallway for 40 feet and denies shortness of breath at rest or with ambulation. T.Y., LPN" C. "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" D. "Vital signs 37.0° C, heart rate 60, respiratory rate 20, blood pressure 110/68, and oximetry 98% on room air. L.D., UAP"
Will the stoma present visual clues of D.S.'s bowel blockage or obstruction?
What will be an ideal response?