The nurse is careful to apply suction prior to deflating the cuff on a cuffed tracheostomy in order to prevent:
a. bleeding.
b. excessive negative pressure.
c. accidental dislodgement of the tube.
d. aspiration.
D
By suctioning prior to deflating the cuff, the oral liquids that are trapped above the balloon can-not be aspirated. Bleeding, negative pressure, and dislodgement of the tube are not related to cuff inflation.
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Nursing interventions to prevent pressure ulcers include all of the following except:
a. use lift devices for transferring or moving patient in bed b. assess each patient for risk c. turn all patients every two hours d. use pressure relieving devices for patients at risk
The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next?
a. Activate the rapid response team. b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.
The nurse is working with first-time parents. Which activity will the nurse suggest to encourage the development of good muscle tone in their infant?
1. Placing the infant in an infant seat rather than lying down in a crib 2. Surrounding the infant with toys and other stimulating items to encourage motor movement 3. Swaddling the infant 4. Putting the infant to bed each night at 8 p.m., even if the infant protests with crying
The nurse instructs parents about the signs of otitis media, which include:
a. earache, wheezing, vomiting. b. coughing, rhinorrhea, headache. c. fever, irritability, pulling on ear. d. wheezing, cough, drainage in ear canal.