Final HESI EXIT Exam Study Guide | Latest 2023/24 | Updated & Verified | Guaranteed Success | 101 Pages

The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take? 1. Leave the cuff inflated and suction through the tracheostomy. 2. Deflate the cuff and suction through the tracheostomy tube. 3. Inflate the cuff pressure to 40 mm Hg before suctioning. 4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. - 1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration; cuff position and pressure should be assessed frequently; swallowing and breathing will cause tracheostomy tube movement 2) Implementation: outcome not desired; accumulated oral secretions above the cuff will drain into the bronchi; increased risk of infection 3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25 cm H2O); risk of trauma to trachea with higher pressures 4) Implementation: outcome not desired; increases the risk of trauma to lower airways A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate? 1. Assess pupil size and reactivity. 2. Assess oxygen saturation levels. 3. Palpate dorsalis pedis pulses. 4. Ask the client if he knows today's date. - 1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin overdose2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas exchange and possible respiratory arrest 3) Assessment: outcome not priority; most important to assess airway and breathing 4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be seen; not priority The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask? 1. "Have you tried other methods to stop smoking?" 2. "How long have you been smoking?" 3. "Have you ever had chest pain?" 4. "Do you have a partial dental bridge?"