A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

examining the character of the sputum

monitoring the rate of respirations.

auscultating the breath sounds

determining the last time the patient was suctioned

Answer and Explanation

The Correct Answer is C

A. Examining the character of the sputum: While monitoring secretions is important, it does not necessarily indicate the need for immediate suctioning.
B. Monitoring the rate of respirations: An increased respiratory rate can indicate distress but is not a definitive cue for suctioning.
C. Auscultating the breath sounds: This helps identify the presence of secretions or airway obstruction and is a primary indicator for suctioning.
D. Determining the last time the patient was suctioned: Suctioning should be based on clinical need rather than a routine schedule.

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Correct Answer is C

Explanation

A. Bradypnea: Hypoxia typically leads to tachypnea as the body attempts to increase oxygen intake.
B. Pallor: While it can be a sign of poor perfusion, cyanosis is more closely associated with hypoxia.
C. Cyanosis: A late sign of severe hypoxia, indicating a lack of oxygen in the tissues.
D. Bradycardia: Hypoxia usually stimulates tachycardia as the body tries to compensate.

A. sitting upright and forward with arms supported on an over the bed table B. semi-Fowler's position with a single pillow behind the head C. high Fowler's position without a pillow behind the head D. right lateral with the head of the bed elevated 45 degrees.

Correct Answer is A

Explanation

A. Sitting upright and forward with arms supported on an over-the-bed table: This tripod position allows for maximum lung expansion by reducing pressure on the diaphragm and improving airflow, especially for patients with chronic obstructive pulmonary disease (COPD).
B. Semi-Fowler's position with a single pillow behind the head: This position does not optimize lung expansion as well as the tripod position.
C. High Fowler's position without a pillow behind the head: Although better than lying flat, this position lacks arm support, which helps in leveraging accessory muscles for breathing.
D. Right lateral with the head of the bed elevated 45 degrees: This position is not beneficial for promoting effective lung expansion in patients with emphysema.

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A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

The nurse assists the patient with emphysema into the most beneficial position to facilitate respiration, which is:

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is having difficulty using an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

A nurse is nasopharyngeal suctioning an adult patient to remove thick secretions. The nurse will:

A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands, and cannot talk. Which of the following actions should the nurse take?

The nurse loosens mucus plugs by using percussion on a patient over the area of the:

The nurse clarifies that the cough mechanism is stimulated when:

The multiple causes for hypoxia include: (Select all that apply.)

The nurse performing tracheostomy care will: