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 A

Explanation

A) Taping all connections within the system. Taping all connections helps prevent air leaks, which can compromise the function of the chest drainage system.
B) Turning on suction to 35 cm. Suction levels are typically set between 10 to 20 cm of water pressure. 35 cm is excessive and may cause lung tissue damage.
C) Keeping the system at the level of the patient's chest. The drainage system should always be kept below the level of the chest to promote gravity drainage and prevent backflow.
D) Looping the tubing between the mattress and the bed rail to minimize length. Tubing should not be looped or kinked, as this can obstruct drainage and compromise system function.

A. Toe B. Skin fold C. Earlobe D. Finger

Correct Answer is C

Explanation

A) Toe. Thickened toenails and edema make this site unreliable for accurate readings.
B) Skin fold. Skin folds are not recommended for pulse oximetry measurements due to poor contact and inconsistent readings.
C) Earlobe. The earlobe is a preferred site in cases of peripheral edema or thickened nails because it has good perfusion and provides reliable readings.
D) Finger. Edema in the hands compromises the accuracy of finger pulse oximetry measurements.

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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

The nurse caring for a patient with a disposable chest drainage system can promote effective tube function and patient safety by:

Correct Answer is A

Explanation

A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

Correct Answer is C

Explanation

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