HESI MED-SURG STUDY GUIDE 2021/2022

HESI MED-SURG STUDY GUIDE

The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat?

Inflate the cuff

Rationale: If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration.

The nurse has implemented a bowel maintenance program for an unconscious client. The nurse would evaluate the plan as best meeting the needs of the client if which method was successful in stimulating a bowel movement? Glycerin suppository

Rationale: The least amount of invasiveness needed to produce a bowel movement is best. Use of glycerin suppositories is the least invasive method and usually stimulates bowel evacuation within a half-hour.