The nurse is caring for a client with a new tracheostomy. After completing a teaching session on tracheostomy care, what should the nurse include in the documentation?

Correct Answer: C

Rationale: Documenting the client's questions after the teaching session is important because it demonstrates the client's understanding of the information provided during the teaching session. It also helps to identify any areas where the client may need further clarification or education. This information is crucial for evaluating the effectiveness of the teaching session and ensuring that the client is able to perform tracheostomy care safely and effectively. Additionally, documenting the client's questions allows for continuity of care by providing insight into the client's concerns and educational needs.

Correct Answer: B

Rationale: It is crucial for parents to be instructed on preventing exposure to infection before their baby's surgery to correct a congenital heart defect. Infections can pose a serious risk to individuals, especially those with preexisting medical conditions like a congenital heart defect. Infection control measures, such as handwashing, avoiding sick contacts, and keeping the environment clean, can help reduce the risk of postoperative complications due to infections. This instruction is important to help ensure the successful outcome of the baby's surgery and recovery process. It is essential for parents to be vigilant in maintaining a hygienic environment and taking necessary precautions to prevent their baby from getting sick prior to the surgery.

Correct Answer: A

Rationale: The most common clinical manifestation of coronary artery disease is chest pain, also known as angina pectoris. This pain is typically described as a pressure, squeezing, tightness, or heaviness in the chest that may radiate to the arms, neck, jaw, shoulders, or back. It is usually triggered by physical exertion or emotional stress and is relieved by rest or medications such as nitroglycerin. Chest pain occurs due to reduced blood flow to the heart muscles caused by atherosclerosis in the coronary arteries. While dyspnea (shortness of breath), irritability, and tachycardia (rapid heart rate) can also be associated with coronary artery disease, chest pain is the hallmark symptom that often prompts individuals to seek medical attention for further evaluation.

Correct Answer: D

Rationale: Disseminated intravascular coagulation (DIC) is a serious condition characterized by both excessive clotting and bleeding throughout the body. The primary goal of care for a client with DIC is to manage and balance the clotting and bleeding tendencies. A key indicator of successful care for a client with DIC is the absence of bleeding, as this suggests that the coagulation process has been stabilized and there is no ongoing clot breakdown leading to bleeding. Monitoring for signs of bleeding, such as petechiae, purpura, ecchymosis, hematuria, and gastrointestinal bleeding, is essential in evaluating the effectiveness of care in a client with DIC. Therefore, the absence of bleeding is the most significant finding that indicates successful care in a client with DIC.

Correct Answer: A

Rationale: Morning headaches that extend into the neck and subside as the day progresses can be indicative of elevated blood pressure, which is a common cause of morning headaches. Increased blood pressure can cause headaches that are usually worse in the morning due to the body's natural circadian rhythms. Monitoring the client's blood pressure and assessing for other signs of hypertension would be important in this case. Tachycardia, otitis media, and swollen lymph nodes are less likely to be associated with the described symptoms.