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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Jaundiced: The yellow discoloration of the skin can interfere with light absorption, affecting the accuracy of the reading.
B. Febrile: An elevated body temperature does not affect the pulse oximeter's accuracy.
C. Obese: Subcutaneous fat does not interfere with the device's light absorption or reading accuracy.
D. Dark-skinned: Higher melanin levels can affect the absorption of light, leading to less accurate readings.
Correct Answer is D
Explanation
A. Clamp the chest tube and place the patient in high Fowler’s position: Clamping the tube may cause tension pneumothorax and should be done only with a specific prescription.
B. Immediately turn the patient to the side of the insertion site: This action does not address the source of constant bubbling.
C. Document findings: Bubbling in the suction chamber can be normal, but documenting without further assessment may overlook potential system issues.
D. Check for air leaks in the drainage system: Constant bubbling may indicate an air leak, which requires immediate assessment and correction.
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