To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?

Questions 46

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HESI Nutrition Exam Questions

Question 1 of 5

To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?

Correct Answer: A

Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.

Question 2 of 5

A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?

Correct Answer: D

Rationale: For a client with a percutaneous endoscopic gastrostomy (PEG) tube, flushing the tube adequately with water before and after use is essential. This action helps prevent clogging and ensures the proper administration of feedings and medications. Choice A is incorrect because pulverizing all medications into a powdery condition is not necessary for PEG tube administration. Choice B is incorrect as squeezing the tube to break up stagnant liquids may damage the tube. Choice C is incorrect because cleansing the skin around the tube daily with hydrogen peroxide can be too harsh and lead to skin irritation.

Question 3 of 5

A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?

Correct Answer: B

Rationale: The correct answer is B. Alprazolam should not be stopped abruptly as it can cause rebound insomnia and nightmares; gradual tapering is necessary. Choice A is incorrect as sedative hypnotics are not primarily used as analgesics. Choice C is incorrect as caffeine can decrease the effects of sedative hypnotics rather than increase them. Choice D is incorrect as there is no specific recommendation to avoid excessive exercise or high temperature related to alprazolam use.

Question 5 of 5

Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?

Correct Answer: A

Rationale: The correct answer is A because monitoring for orthostatic hypotension is crucial when clients are receiving antipsychotic drugs since it is a common side effect. Orthostatic hypotension can lead to symptoms like dizziness and falls, making it essential to monitor blood pressure regularly. Choices B, C, and D are incorrect because most antipsychotic drugs do not typically cause elevated blood pressure, monitoring blood pressure is not directly related to the amount of sodium in the diet, and blood pressure monitoring is not primarily used to determine the need for anti-parkinsonian drugs in clients receiving antipsychotic medications.

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