Unit I: Stress and Coping

A nurse is caring for a client with a new diagnosis of panic disorder. Which of the following symptoms should the client expect between attacks? A. Belief that the client's thoughts will influence outcomes B. Fear of another attack C. Severe anxiety D. Fear of leaving the house

B, Fear of another attack Individuals with panic disorder have discrete episodes of incapacitating anxiety (panic attacks) that usually last for 15-30 minutes. Panic attacks have a rapid onset and escalation, causing significant emotional and physical discomfort. The disorder can be diagnosed when the client has recurrent panic attacks separated by at least 1 month of persistent worry about a future attack or a significant related behavioral change. During a panic attack, the individual will not be able to think rationally and will benefit from reassurance that the distressing physical and emotional symptoms will resolve and will not result in death or collapse. Panic attacks can be treated with SSRI antidepressants and cognitive behavioral therapy.

A nurse is assessing a client who has generalized anxiety disorder and is trembling and pacing during a group activity. The nurse also notes the client's voice trembles when speaking. Which of the following statements should the nurse make to the client? A. "Most clients who have anxiety issues benefit from lying down." B. "Come with me to an area where we can talk without interruption." C. "You should talk to your doctor about relaxation exercises for you when you are upset." D. "An antianxiety pill works best for situations like this."

B. "Come with me to an area where we can talk without interruption." With this response, the nurse is using the therapeutic communication technique of offering self. By respecting the client's privacy and showing a willingness to listen, the nurse is demonstrating empathy.

The nurse is caring for a client who is undergoing a tracheostomy. Which of the following complications is associated with this procedure? A. Decreased cardiac output B. Damage to the laryngeal nerve C. Pneumothorax D. Acute respiratory distress syndrome

B. Damage to the laryngeal nerve A tracheostomy is a procedure to create an opening in the neck through which a tube can be placed directly into the trachea. The procedure can be performed surgically or percutaneously (through the skin of the neck.) It is indicated for clients who cannot wean from the ventilator, those with upper airway obstruction, and those with neurologic disorders requiring long-term mechanical ventilation. Complications include damage to the recurrent laryngeal nerve, bleeding, infection, subcutaneous emphysema, and damage to the posterior wall of the trachea.

Which of the following are considered contraindications for inserting nasogastric tubes? Select all that apply. A. Mechanical bowel obstruction B. Trauma to the patient's face C. Esophageal strictures D. Dysphagia or odynophagia E. Paralytic ileus

B. Trauma to the patient's face C. Esophageal strictures A nasogastric tube is inserted into the patient's nose and threaded to the stomach in certain situations, such as when the patient has difficulty swallowing or has intestinal conditions that complicate digestion. There are also some conditions in which a patient should not have a nasogastric tube placed, such as when there is trauma to the patient's face, a condition such as a basilar skull fracture, or when there are potential obstructions in the esophagus, such as esophageal strictures.

A nurse is placing a nasogastric tube in an elderly client who begins to gag and choke. Which of the following interventions should the nurse prioritize? A. Remove the tube completely and try to insert it through the opposite nares. B. Withdraw the tube slightly and wait to proceed until gagging and choking stops. C. Oxygenate the client and notify the healthcare provider. D. Move the tube forward quickly.

B. Withdraw the tube slightly and wait to proceed until gagging and choking stops. Before placing a nasogastric tube, the nurse should let the client know that although the procedure is not painful, it stimulates the gag reflex and may cause coughing. When the nurse is passing the tube at the oropharynx, the client may begin to gag. If the client begins to gag, the nurse should ask the client to tilt the head forward, stop passing the tube, and encourage the client to take a few breaths and some sips of water. With the client's help, the nurse can pass the tube 2-4 inches (5-10 cm) with each swallow until it has been inserted to the correct depth (measured length). If the gagging or choking continues, the nurse should look through the mouth to determine if the tube is coiled in the throat. If so, it can be withdrawn slightly until it straightens, and another attempt can be made to pass the tube.

A nurse is caring for a client who is to begin taking paroxetine for treatment of generalized anxiety disorder. Which of the following statements indicates that the client understands the use of this medication? A. "I will take the medication at bedtime." B. "I should expect to have an elevated temperature while taking this medication." C. "I should not stop this medication abruptly." D. "I will weigh myself once each month."

C, "I should not stop this medication abruptly." Abrupt discontinuation of paroxetine can cause manifestations such as dizziness, hallucinations, agitation, anxiety, nausea, and sweating. When discontinuing paroxetine, the client should taper the medication slowly according to a prescribed tapered dosing schedule to reduce the risk for withdrawal syndrome.

A nurse is caring for a client who has panic disorder and is pacing the floor and speaking rapidly in the middle of the night. The client reports having difficulty sleeping and is diaphoretic. Which of the following actions should the nurse take? A. Encourage the client to go back to bed. B Administer zolpidem to the client. C. Remain with the client. D. Explore alternatives to pacing the floor with the client.

C, Remain with the client A client who is experiencing a severe level of anxiety has a very restricted sense of the surrounding environment. They can be confused and are at risk for injury. Remaining near the client will help to alleviate feelings of abandonment and reassure the client of their safety

The nurse is working on the medical-surgical floor caring for a client who has a tracheostomy tube in place. On their care plan, it is indicated the client should receive nasotracheal suctioning every four hours. When the nurse goes to suction the client at 8 am and 12 pm, they note the client has a copious amount of secretions that cannot be expectorated and that their breath sounds reveal rhonchi. What is the appropriate response by the nurse? A. Advise the client to take several deep breaths prior to suctioning every four hours B. Encourage the client to clean their trach tube hourly C. Change the client's care plan to indicate they should be suctioned every two hours D. Instruct the unlicensed assistive personnel how to perform nasotracheal suction they can do it when needed

C. Change the client's care plan to indicate they should be suctioned every two hours The nurse should recognize when changes to the client care plan are needed and take steps to make those changes when appropriate.

A nurse assesses a client for placement of a nasogastric tube by aspirating the stomach contents and determining the pH value of the aspirate. Which of the following values indicates incorrect placement? A. 3.8 B. 4.0 C. 2.9 D. 7.4

D. 7.4 Before feeding is initiated through an NG tube, placement is usually confirmed by X-ray. When placement is confirmed, the nurse marks the tube with indelible ink at the exit point from the nose; tape can also be used. The length of visible tubing is documented by the nurse and can be used as a baseline, but the nurse should verify placement of the tube in the GI tract before each intermittent feeding and at regular intervals (usually every 4 or 8 hours) if continuous feedings are prescribed. Placement can be evaluated by aspiration and visualization of gastric secretions, measurement of the pH of aspirate, or, less reliably, by auscultation of the epigastrium while injecting 5-20 mL of air; gurgling or whooshing is heard if the tube is in the stomach. Gastric aspirate usually has a pH of 1-4 (highly acidic), but the pH can be as high as 6 if the client is taking a medication that suppresses gastric acid. The nurse should realize that a pH of 7.4 would indicate an incorrect placement of the tube. Respiratory secretions usually have a pH of 7 or greater.

A nurse is caring for a client who has an NG tube in place and a new prescription for a sublingual (SL) medication. Which of the following actions should the nurse take? A. Request a prescription for a different formulation of the medication. B. Hold the medication until the NG tube is removed. C. Dissolve the medication in water and give it through the NG tube. D. Administer the medication under the client's tongue.

D. Administer the medication under the client's tongue. The nurse should administer the sublingual medication under the client's tongue. Sublingual preparations work via direct absorption into the bloodstream. Swallowing it exposes it to gastric juices, which can inactivate the medication

A nurse is preparing to administer an enteral feeding through a client's NG tube. For which of the following purposes should the nurse measure the client's gastric residual? A. To confirm the placement of the NG tube B. To remove gastric acid that might cause dyspepsia C. To determine the client's risk for aspiration. D. To identify delayed gastric emptying

D. To identify delayed gastric emptying The nurse should measure the amount of unabsorbed formula from the previous enteral feeding to identify delayed gastric emptying. If it is delayed, the nurse should avoid overfeeding the client, which can cause gastric distention.

The nurse is changing the ties on a recently placed tracheostomy tube. The tube suddenly becomes dislodged when the client moves unexpectedly. What is the nurse's priority action? A. Replace the tube B. Call the healthcare provider to reinsert the tube C. Cover the stoma with a sterile dressing to prevent entry of infectious microorganisms D.Spread the opening by grasping the retention sutures

D.Spread the opening by grasping the retention sutures A tracheostomy tube is placed through a surgical incision in the trachea, below the larynx, and extending caudally into the trachea. The tube has an outer cannula with a flange that rests on the neck, securing the tube with ties or tapes. The obturator is used to insert the tube, after which it is removed. The obturator should be kept at the bedside if the tube becomes dislodged. Some tubes have an inner cannula that is removed for cleaning or (if disposable) may be replaced. The stoma may close quickly if the tube is dislodged in clients with a new or recently placed tracheostomy. If accidental decannulation occurs, the nurse should pull the retention sutures placed on either side of the stoma, if there, to maintain patency. After calling for help, the nurse should reassure the client and encourage normal breathing. After the tracheostomy tube has been replaced, the nurse should tie it securely, leaving a fingerbreadth between the neck and the ties. To prevent the tube from dislodging when the ties are soiled or challenging to thread, the nurse can have an assistant hold the tracheostomy in place with a sterilely gloved hand.

Vital Concept: Tracheostomy

Tracheostomy suctioning removes thick mucus and secretions from the trachea and lower airway that the client is not able to clear by coughing. 2.) Position the client comfortably with his or her head and neck well-supported. After proper hand hygiene, the nurse will fill a small paper cup about half-way with distilled water. The clean glove is placed on the dominant hand. If the client has a cuffed tracheostomy tube, check to see if the cuff is properly inflated. After opening the suction catheter package, the nurse will pick up the hard plastic end of the catheter with the gloved hand and attach it to the connecting tubing. The catheter should be wrapped around the gloved hand when not in use to avoid contamination of the catheter. The nurse will turn on the suction machine with the ungloved hand and expose the client's tracheostomy opening. With the finger off the suction vent, the nurse will gently insert the suction catheter into the tracheostomy opening and slowly advance the catheter a maximum of 6 inches or until meeting resistance. Covering the suction vent with the thumb of the ungloved hand to apply suction, the nurse will withdraw the catheter and rotate, using a slow and even motion. The catheter should be rolled between the thumb and forefinger of the gloved hand, applying suction as the catheter is withdrawn. Suction should not be applied for longer than 10 seconds. The catheter and connecting tubing should be cleaned between each suction pass by dipping the catheter into the distilled water, placing the finger over the suction vent and drawing up small amounts of distilled water through the catheter. The contents of the catheter are emptied into the collection basin. The client should be given 20 to 30 seconds to rest between suction passes.

A nurse must insert a nasogastric tube for delivery of enteral formula and medication. Place the following in the proper order for inserting a nasogastric tube. -Position the client in the high Fowler's position -Lubricate the end of the tube -Encourage the client to swallow while advancing the tube -Determine the length of the tube by measurement from the tip of the nose to the earlobe to the xiphoid process -Secure the tube to the client's nose -Insert the end of the tube into the end of the nostril and guide it towards the back of the throat -Confirm tube placement by aspirating stomach contents

1.Position the client in the high Fowler's position 2.Determine the length of the tube by measurement from the tip of the nose to the earlobe to the xiphoid process 3.Lubricate the end of the tube 4.Insert the end of the tube into the end of the nostril and guide it towards the back of the throat 5.Encourage the client to swallow while advancing the tube 6.Confirm tube placement by aspirating stomach contents 7.Secure the tube to the client's nose

Which of the following measures should be implemented promptly after a client's nasogastric (NG) tube has been removed? A. Provide the client with oral hygiene B. Offer the client liquids to drink C. Encourage the client to cough and deep breathe D. Auscultate the client's bowel sounds

A. Provide the client with oral hygiene The first action is to provide mouth care. Then, if appropriate and no longer on oral restrictions, oral liquids should be allowed.

A nurse is about to administer an enteral feeding through a client's NG tube. Which of the following actions should the nurse take first? A. Aspirate the client's stomach contents. B. Hang the feeding bag 30 cm (12 in) above the client. C. Flush the tube with 30 mL of water. D. Warm the formula to room temperature.

A. Aspirate the client's stomach contents. The first action the nurse should take when using the nursing process is to assess the residual stomach contents. The nurse should measure the stomach contents to determine whether the client's gastrointestinal system is absorbing the formula at an acceptable rate. The nurse might delay the tube feeding if there is a high volume of residual to reduce the risk for aspiration.

**A nurse is assessing the peripheral IV infusion site of a client who reports pain at the insertion site. The nurse finds erythema and a streak formation at the site. Which of the following actions should the nurse take? A. Remove the catheter and insert another at a different site. B. Administer an analgesic PO. C. Request a prescription for placement of a central venous access device. D. Apply an ice pack to the reddened area at the site.

A. Remove the catheter and insert another at a different site. These findings can indicate phlebitis at the IV insertion site. The nurse should stop the infusion, remove the IV catheter, and establish peripheral IV access elsewhere. Manifestations of phlebitis can include: • Redness • Tenderness • Pain • Warmth along the course of the vein starting at access site • Red streak • Palpable cord along the vein

A nurse is maintaining an intravenous site. Which of the following interventions must be implemented to maintain the IV system? (Select all that apply) A. Change gauze dressing every 48 hours B. Disconnect infusion tubing when changing client's gown C. Change midline injection cap at least once a week D. Change the tubing for intermittent infusion through an access port every 24 hours G. Fluid container should be changed every 24 hours

A. Change gauze dressing every 48 hours C. Change midline injection cap at least once a week D. Change the tubing for intermittent infusion through an access port every 24 hours The maintenance of an IV (intravenous) system is critical for the safety and recovery of the client. Infiltration, systemic infection, and phlebitis can occur if the IV line is not managed appropriately. Nurses communicate with and evaluate the client round the clock, while doctors and other health care team members are not always at the bedside. The INS (infusion nursing standard) guides practice in implementing the IV system. According to the INS; gauze dressing is changed routinely every 48 hours -- not every 24 hours -- to maximize its usage; infusion tubing is not disconnected when changing client's gown, to maintain a continuous system; midline injection cap is changed at least once a week to prevent accumulation of microorganisms; tubing for intermittent infusion through an access port is changed every 24 hours to minimize risk of infection; the site is covered with transparent membrane or sterile gauze dressing and not thick dressing to provide easy transition and ease for the client; and the fluid container is changed as needed rather than every 24 hours.

A nurse is caring for a client who has a nasogastric (NG) tube connected to wall suction. Which of the following should the nurse do when administering a medication through the NG tube? A. Clamp the nasogastric tube for 30 minutes after the medication is administered. B. After giving the medication, set the NG tube on low intermittent suction for 30 minutes. C. Position the client in the supine position so the medication will be better absorbed. D. Aspirate the NG tube after giving the medication.

A. Clamp the nasogastric tube for 30 minutes after the medication is administered. . The nurse should always check with the pharmacist to determine if the prescribed medication is available in a liquid form, but if a liquid form is not available, the nurse must ensure that the medication can be safely crushed. Crushed tablets should be dissolved in warm water. If the tube is connected to wall suction, the suction should be disconnected, and the tube should be clamped for 30 minutes after administration of the medication to allow absorption. Before administering medications, the nurse should check and confirm placement of the tube.

A nurse is caring for a client with a tracheostomy who is conscious and beginning to advance his oral intake. Which of the following actions should the nurse perform to reduce the risk of aspiration when feeding? (Select all that apply.) A. Deflate the cuff before feeding B. Give pureed foods C. Inflate the cuff before feeding D. Ask the client to sit upright during feeding, with the chin in flexion

A. Deflate the cuff before feeding D. Ask the client to sit upright during feeding, with the chin in flexion The cuff on a tracheostomy tube should be used when a client is unconscious or mechanically ventilated, with increased risk of aspiration. However, there is a higher rate of aspiration and respiratory infections for a client with a tracheostomy who has an inflated cuff instead of a deflated cuff. When clients are awake, the inflated cuff may make talking or swallowing difficult and can be uncomfortable. When the client is awake and no longer at risk of aspiration, the cuff should be deflated after asking the client to cough in order to expectorate any oropharyngeal secretions above the inflated cuff. After this maneuver, apply suction through the tracheostomy tube and mouth before deflation. The client should sit upright, with the chin slightly flexed. The nurse should monitor for fever, which may be associated with aspiration pneumonia, as well as for garbled voice or wet lung sounds.

A nurse is preparing to administer a nasogastric (NG) tube feeding to a client. Which of the following actions should the nurse take? A. Determine tube placement by aspirating and checking the pH of the secretions. B. Follow the feeding solution with 100 mL of water. C. Use the plunger of the syringe to gently push the feeding through the tube. D. Chill the feeding solution prior to administration.

A. Determine tube placement by aspirating and checking the pH of the secretions. The nurse should check the placement of the tube by aspirating secretions and checking the pH levels of the secretions. A pH of 6 or greater indicates intestinal or pulmonary placement.

When placing a nasogastric tube in an adult client, the nurse knows that which of the following actions will ensure an accurate measurement of the length of the tube to be inserted? A. Place the tube at the tip of the nose and extend to earlobe then down to the xiphoid process. B. Place tube at the tip of the nose, extend to the earlobe, and mark at top of the sternum. C. Mark the tube at 12 inches. D. Mark the tube at 30 inches.

A. Place the tube at the tip of the nose and extend to earlobe then down to the xiphoid process. A nasogastric tube is used to administer tube feedings and medications for clients who are unable to eat by mouth, including those who are unable to swallow adequately without aspirating food or liquids into the lungs. The nasogastric tube's depth of insertion is estimated by placing the tube at the tip of the nose and extending to earlobe then down to the xiphoid process. The average length of the inserted portion of the nasogastric tube for an adult is 22-26 inches. Before feeding is initiated through an NG tube, placement is usually confirmed by X-ray. When placement is confirmed, the nurse marks the tube with indelible ink at the exit point from the nose. Tape can also be used.

Which of the following interventions does a nurse anticipate when planning care for a client who has a small bowel obstruction who has a nasogastric tube in place? (Select all that apply.) A. Provide oral hygiene every 2 hours B. Monitor the placement of the nasogastric tube every 24 hours C. Document nasogastric drainage along with other client output D. Assess bowel sounds E. Irrigate the nasogastric tube every shift

A. Provide oral hygiene every 2 hours C. Document nasogastric drainage along with other client output D. Assess bowel sounds A nasogastric tube is used to reduce abdominal distention and prevent emesis in individuals with small bowel obstruction. Drainage should be monitored every 4 hours. Since the client breathes primarily through the mouth when the NG tube is in place, oral hygiene should be provided for comfort. Bowel sounds should be assessed to determine if the obstruction is resolving and if the bowel is active.

Before a nurse removes an NG tube from a client, what should the nurse instruct the client to do? A. Take a deep breath and hold it B. Perform a Valsalva maneuver C. Exhale D. Inhale deeply and exhale rapidly

A. Take a deep breath and hold it A nasogastric tube is used to administer tube feedings and medications for clients who are unable to eat by mouth, including those who are unable to swallow adequately without aspirating food or liquids into the lungs. They are also used to facilitate suctioning stomach contents for prevention of nausea, vomiting, and gastric distention and to remove stomach contents for analysis. When removing a nasogastric tube, the nurse should assist the client to a seated position if possible, placing a disposable pad across the client's chest to shield it from spillage. The tube should be disconnected and unpinned from the client's gown. Before removing the tube, the nurse may instill 50 mL of air to clear the tube of any contents, but this is optional. Instruct the client to take a deep breath and hold it, which will close the epiglottis and allow the tube to pass easily through the esophagus into the nose. The NG tube should be pinched to prevent contents from draining into the client's throat and removed with a smooth, continuous motion.

A client who has been diagnosed with social phobia and anxiety is undergoing cognitive behavioral therapy. This therapy includes which of the following interventions and techniques?(Select all that apply.) A. Teaching techniques to reframe thought patterns B. Relaxation techniques C. Discussing the origin of the client's current coping mechanism D. Exploring the client's relationship with family members E. Desensitization to certain situations and stimuli

A. Teaching techniques to reframe thought patterns B. Relaxation techniques E. Desensitization to certain situations and stimuli Cognitive behavioral therapy is an effective method of treating a variety of medical and psychological disorders, including anxiety disorders (phobia, generalized anxiety disorders), depressive disorders, and eating disorders. It has also been successfully used in the treatment of tobacco dependence and insomnia. Cognitive behavioral therapy teaches the individual to recognize maladaptive behaviors and thoughts that occur when confronted with anxiety, conflict, or other stressors and to substitute healthier coping mechanisms. The components of CBT include the following: • Education about the disorder • Self-monitoring and recognition of anxiety, assessment of severity, and specific triggers • Strategies to control physical, involuntary reactions to anxiety-provoking stimuli, including relaxation exercises and deep-breathing • Strategies to reframe unproductive thinking patterns and to challenge negative thoughts and assumptions • Behavioral modification focused on forming new behavioral responses to stimuli and situations that cause anxiety and desensitization to events or situations that cause anxiety

A nurse is caring for a client who has a nasogastric tube that is connected to low-intermittent suction. Which method is most appropriate for determining if the suction is working appropriately? A. Temporarily disconnect the tubing between the NG and the drainage tube and listen for suction noises. B. Turn up the suction on the wall-mounted device and listen with a stethoscope over the client's abdomen C. Instill 10 mL of air into the NG tube and listen with a stethoscope over the client's abdomen D. Record the volume in the suction container every four hours.

A. Temporarily disconnect the tubing between the NG and the drainage tube and listen for suction noises. A nurse who is caring for a client who is undergoing gastric decompression by low-intermittent suction must monitor regularly to ensure that the suction is working and set at the appropriate level. To do this, the nurse should temporarily disconnect the tubing between the NG and the drainage tube and listen for suction. The most common nasogastric tube used for gastric decompression is the double-lumen gastric (Salem) sump tube. It is made of clear plastic and sized according to the French method. The Salem tube can be used to irrigate the stomach or to draw fluid and gas from the stomach.

Select the complication of intravenous therapy that is correctly paired with one of its signs or symptoms. A. Catheter embolus: Ecchymosis at the insertion site B. Extravasation: Extreme pain at the site C. Phlebitis: Tachycardia D. Cellulitis: Shortness of breath

B. Extravasation: Extreme pain at the site Nurses must be highly knowledgeable about the complications of intravenous therapy as well as their signs and symptoms. One of the signs of extravasation is extreme pain at the site. Extravasation is defined as the infiltration of a vesicant drug, such as a chemotherapeutic agent.

A nurse is caring for a client with a tracheostomy. Which of the following will the nurse do when suctioning the client? A. Use a new sterile suction catheter with each insertion B. Initiate suction as the catheter is being withdrawn C. Insert the catheter until the cough reflex is stimulated D. Remove the inner cannula before suctioning is initiated

B. Initiate suction as the catheter is being withdrawn Suction should not be initiated until the catheter is ready to be withdrawn because suctioning causes hypoxia in addition to removal of secretions.

A nurse is assessing a client who has an NG tube with suction applied. The nurse finds that the client's respiratory rate and depth of respirations have decreased. The nurse should identify the client is experiencing which of the following acid-base imbalances? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis The nurse should identify that a client who has an NG tube with suction applied is at risk for developing metabolic alkalosis. Manifestations include a decrease in the depth and rate of respirations, dizziness, circumoral paresthesia, and numbness and tingling of the extremities.

A nurse is caring for a client who is experiencing a crisis due to the sudden death of her partner. The nurse should anticipate that the provider might prescribe which of the following medications? (Select all that apply.) A. Carbamazepine B. Paroxetine C. Risperidone D. Benztropine E. Lorazepam

B. Paroxetine E. Lorazepam SSRI antidepressants, such as paroxetine, can be prescribed to decrease the anxiety and depression of a client who is experiencing a crisis. Benzodiazepines, such as lorazepam, can be prescribed to decrease the anxiety of a client who is experiencing a crisis.

**A nurse started a peripheral IV on a client 24 hours earlier and is administering lactated Ringer's solution with electrolytes at a rate of 125 mL/hr. The client complains of burning at the IV insertion site and the nurse notes that the site is red and puffy, and there is a red streak extending across the hand from the insertion site. The nurse suspects the client most likely has: A. Extravasation B. Phlebitis C. Infiltration D. Hypersensitivity

B. Phlebitis Phlebitis can develop in a peripheral IV of any solution, but it may occur more often with some fluids that are irritating to the veins or when an IV is placed in a vein that is too small. Phlebitis causes pain, swelling, and edema at the site; the client may also have a red streak or mark at the catheter site that extends across the skin.

A nurse is providing teaching about home tracheostomy care to the partner of a client who is to be discharged. When considering cost-effective care, which of the following instructions should the nurse give to the partner? A. Wear clean gloves when suctioning the client's tracheostomy. B. Rinse and dry suction catheters and reuse for up to 24 hr. C. Empty and rinse the suction container in a sink every 24 hr. D. Discard oral suction tubes (Yankauer) after each use.

B. Rinse and dry suction catheters and reuse for up to 24 hr. In the home setting, suction catheters can be reused for up to 24 hours. Catheters should be flushed between each use utilizing distilled water or recently boiled water and allowed to air dry.

A nurse in a mental health facility is admitting a client who has generalized anxiety disorder and has become aggressive to other clients and staff. After showing the client to his room, which of the following actions should the nurse take next? A. Suggest that the client rest in bed. B. Stay with the client for a while. C. Administer a sedative to the client. D. Encourage the client to join an activity with others.

B. Stay with the client for a while. Stay with the client for a while. Rationale B. When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should remain with a client who has anxiety. The nurse should stay with the client to encourage him to express his feelings, which might help to lower his anxiety level.

A nurse is caring for a client who has been diagnosed with generalized anxiety disorder. Which of the following is an example of interpersonal communication by the nurse? A. The nurse informs the healthcare team of the client's response to a medication for anxiety. B. The nurse asks the client when the anxiety attacks began and how frequently they occur. C. The nurse presents an educational program at a community health fair to explain different types of anxiety disorders and local resources. D. The nurse considers his feelings about individuals who suffer from anxiety disorders.

B. The nurse asks the client when the anxiety attacks began and how frequently they occur. Interpersonal communication occurs between two individuals on a one-on-one basis. Examples of interpersonal communication between a nurse and client include obtaining a personal history and asking open-ended questions to allow the client to explore feelings.

Which of the following actions should the nurse implement in order to prevent complications when changing IV tubing, injection caps, and dressing for a PICC (peripherally inserted central catheter) line for a client receiving total parenteral nutrition? (Select all that apply.) A. Instruct the client to move the head to the side of the dressing change. B. Thoroughly wash hands before and after the procedure. C. Place the client in the reverse Trendelenburg position before beginning the procedure. D. Sterile gloves are the only PPE necessary. E. Ask the client to take a deep breath and hold it when changing injection caps and tubing.

B. Thoroughly wash hands before and after the procedure. E. Ask the client to take a deep breath and hold it when changing injection caps and tubing. Clients who require long-term total parenteral nutrition, antibiotics, or chemotherapy may have a PICC line placed. Infection can occur if the PICC line is contaminated. Other complications include air embolism, phlebitis, and catheter occlusion. When changing the dressing for a central line, the nurse uses sterile technique, including a mask to prevent contamination of the line by respiratory secretions. The client should also be asked to hold the head in the opposite direction of the dressing change to prevent contamination of the procedure by any microorganisms in the client's respiratory secretions. Instructing the client to perform a Valsalva maneuver or hold a breath is indicated to prevent entrance of air into the line when caps and tubing are replaced in order to reduce the risk of formation of air embolism.

A client is receiving peripheral parenteral nutrition (PPN) and has had the same IV in place for 3 days. Although the site appears normal, the nurse removes the IV and starts a new one in a different location to infuse the PPN. What is the most likely rationale for this action? A. To prevent backup of blood that can cause clotting in the catheter B. To reduce the risk of phlebitis and infiltration at the site C. To reduce the risk of deep vein thrombosis D. To teach the client the importance of aseptic technique

B. To reduce the risk of phlebitis and infiltration at the site Keeping an IV in the same place for a long period of time increases the risk of developing phlebitis or infiltration at the site. The nurse most likely changed the IV site to reduce this risk.

A nurse is assessing a client who has an NG tube in place that is set to low gastric suction for gastric decompression to treat abdominal distention. The client reports anxiety, discomfort, and bloating. Which of the following actions is the nurse's priority? A. Request an X-ray to verify NG tube placement. B. Irrigate the NG tube with 30 mL of irrigant. C. Check to see if the suction equipment is working. D. Remove and reinsert the NG tube.

C. Check to see if the suction equipment is working. The first action the nurse should take when using the nursing process is to assess the situation. The nurse should first check for the most likely reason for the client's discomfort. If the suction equipment is not on or is malfunctioning, the nurse should adjust it or replace it with working equipment.

A nurse is caring for a client who is undergoing tracheostomy. The nurse understands that which of the following is a complication of this procedure? A. Increased work of breathing B. Decreased cardiac output C. Damage to the recurrent laryngeal nerve D. Respiratory distress syndrome

C. Damage to the recurrent laryngeal nerve A tracheostomy can lead to laryngeal nerve damage and infection.

**A nurse is caring for a client who is receiving an IV infusion via an infusion site in the left hand. Which of the following findings should the nurse identify as an indication of an infiltration? A. Blood in the IV tubing B. Red streak along the vein C. Edema in the palm of the hand D. Warmth around the insertion site

C. Edema in the palm of the hand The nurse should identify that edema, pallor, and coolness around the insertion site can indicate an infiltration, which is a collection of fluid leaking into the subcutaneous tissue.

While caring for a client who has a nasogastric feeding tube, the nurse prepares his next enteral feeding. Before administering the feeding, the nurse checks the gastric residual and notes that the residual amount is 550 mL. Which of the following actions by the nurse are most appropriate? (Select all that apply.) A. Place the client in the Trendelenburg position B. Return half of the gastric residual and discard the rest C. Notify the physician D. Withhold the next feeding E. Wait one hour and administer the feeding.

C. Notify the physician D. Withhold the next feeding When caring for a client who has an NG tube, the nurse must check placement of the tube and for any residual that is still in the stomach before administering more feedings. If a large amount of residual is present, the nurse should notify the physician and hold the feeding. The nurse should then check the residual level again in about an hour to see if the client is continuing to digest the formula.

A nurse is monitoring a client who is receiving a peripheral infusion. Which of the following will the nurse expect to see if extravasation occurs? A. Redness and swelling with a red streak traveling up the extremity B. Throbbing pain and a bruise or blood-filled lump at the IV site C. Redness, burning pain, and tissue sloughing or necrosis D. Fever, tachycardia, and pain that migrates through the body

C. Redness, burning pain, and tissue sloughing or necrosis Extravasation occurs with infiltration of caustic fluids into the tissues surrounding the vein. Caustic fluids, or vesicants, include such substances as chemotherapy drugs that are damaging to tissues. Extravasation causes redness and burning pain at the site; the skin may blister or slough and may become necrotic if not treated promptly.

A nurse is caring for a client who has just had a nasogastric tube placed. Which of the following signs or symptoms should the nurse assess for that may be initial complications of a nasogastric tube? (Select all that apply.) A. Skin breakdown on the lips B. Excess flatus C. Pain in the neck and shoulders D. Epigastric pain E. Aspiration pneumonia

D. Epigastric pain E. Aspiration pneumonia A nasogastric tube can be inserted easily and quickly to provide feedings for a client or to decompress the stomach, if needed. However, there are several potential complications that the nurse should routinely assess for, including skin breakdown from the tape on the nose or face, pain in the epigastric area, and signs of aspiration, which could cause pneumonia.

A nurse is caring for a client with a fenestrated tracheostomy tube. What is the purpose of a fenestrated trach tube? A. It allows a stylet to be introduced through the tracheostomy B. It reduces the risk of infection by promoting mucous drainage. C. It is used to keep the stoma from closing. D. It allows air to pass over the vocal cords to enable the client to talk with a tracheostomy in place.

D. It allows air to pass over the vocal cords to enable the client to talk with a tracheostomy in place. A fenestrated tracheostomy tube has holes on the posterior aspect of the outer cannula, above the cuff. It is used to allow the client to breathe normally, cough, and speak when the tube is in place. A fenestrated tube is often used as a "step-down" tube before extubation is attempted.

A nurse is caring for a client who was recently diagnosed with terminal cancer. The client states, "This is a mistake. I can't be dying!" Which of the following types of crisis is the client experiencing? A. Adventitious B. Internal C. Maturational D. Situational

D. Situational A terminal diagnosis is a situational crisis, which is a crisis that is unexpected but is a part of regular life, such as a serious illness or financial loss.

A nurse is preparing to remove a nasogastric tube. What instruction should the nurse give to the client? A. Say something B. Lean forward C. Breathe normally D. Take a deep breath and hold it

D. Take a deep breath and hold it Taking a deep breath and holding it closes the glottis, thereby preventing accidental aspiration of the gastric contents.

A nurse is about to instill enteral formula via a client's NG tube. Which of the following actions should the nurse take prior to administering the enteral feeding? A. Warm the formula to body temperature. B. Place the client in a side-lying position. C. Discard any residual gastric contents. D. Test the pH of gastric aspirate.

D. Test the pH of gastric aspirate. Before administering enteral feedings, the nurse should verify the placement of the NG tube. The only reliable method for this is X-ray confirmation, which is impractical prior to every feeding. Testing the pH of gastric aspirate is an acceptable method to use between X-ray confirmations.