A nurse is caring for a client who has a tracheostomy.

Based on the Nurses Notes and Diagnostic Results, which of the following is a manifestation in the client?

The client appears restless.

The client’s SaO2 is 92% on 40% humidified oxygen via tracheostomy collar.

The client’s lung fields have scattered rhonchi throughout.

The client’s tracheostomy was suctioned for thin clear secretions.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Restlessness in a client with a tracheostomy could indicate respiratory distress or hypoxia. It’s important for the nurse to further assess the client’s vital signs, oxygen saturation, and overall appearance.
Choice B rationale
A SaO2 of 92% on 40% humidified oxygen via tracheostomy collar is within the acceptable range for a client with a tracheostomy. However, it’s important to consider the client’s baseline SaO2 and any changes in their condition.
Choice C rationale
Scattered rhonchi throughout the lung fields could indicate secretions in the airways. However, this finding alone does not necessarily indicate a problem with the tracheostomy.
Choice D rationale
Suctioning of thin clear secretions from a tracheostomy is a routine part of tracheostomy care. This finding does not necessarily indicate a problem with the tracheostomy.

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Correct Answer is C

Explanation

Choice A rationale
Placing a tracheostomy tray at the client’s bedside is not the first action a nurse should take when a client is diagnosed with ARDS. While a tracheostomy may be necessary in some cases, it is not the immediate priority.
Choice B rationale
Administering IV prophylaxis for thromboembolism is important in the management of ARDS, but it is not the first action a nurse should take. The immediate priority is to ensure adequate oxygenation.
Choice C rationale
Preparing to assist with intubation of the client is the first action a nurse should take when a client is diagnosed with ARDS. Intubation and mechanical ventilation are often required to ensure adequate oxygenation in clients with ARDS3.
Choice D rationale
Administering IV prophylaxis for stress ulcers is important in the management of ARDS, but it is not the first action a nurse should take. The immediate priority is to ensure adequate oxygenation.

A. Skin breakdown. B. Pneumonia. C. Thrombosis. D. Atelectasis.

Correct Answer is D

Explanation

Choice A rationale
While skin breakdown can occur due to prolonged bed rest, it is not directly related to shallow respirations and refusal to cough or get out of bed.
Choice B rationale
Pneumonia is a possible complication due to immobility and shallow breathing. However, it is not the most immediate risk for a postoperative client who is refusing to cough or get out of bed.
Choice C rationale
Thrombosis is a risk associated with immobility, but it is not directly related to shallow respirations.
Choice D rationale
Atelectasis, or the collapse of alveoli in the lungs, is a common complication after surgery due to shallow breathing and lack of movement. This condition leads to reduced or absent gas exchange, which can further complicate the client’s recovery.

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A nurse is caring for a client who has a tracheostomy. Based on the Nurses Notes and Diagnostic Results, which of the following is a manifestation in the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been diagnosed in the Emergency Department with acute respiratory distress syndrome (ARDS). Which of the following actions should a nurse perform first?

Correct Answer is C

Explanation

A nurse is caring for a postoperative client experiencing shallow respirations and refusing to cough or get out of bed to the chair. The nurse should educate the client about the increased risk of which complication?

Correct Answer is D

Explanation

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A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan of care?

A patient diagnosed with a pulmonary embolism is receiving a continuous Heparin infusion. Which findings should prompt the nurse to notify the healthcare provider?

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A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which precaution should the nurse prioritize when administering nasal oxygen therapy to the client?

A nurse is developing a plan of care for a patient on a ventilator, to prevent ventilator-associated pneumonia. The nurse recognizes that which of the following interventions should be included? Select all that apply.

A nurse is caring for a client who has a tracheostomy.

Based on the Nurses Notes and Diagnostic Results, which of the following is a manifestation in the client?