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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Dyspnea, or difficulty breathing, is a common symptom of Obstructive Sleep Apnea (OSA). This occurs due to the repeated episodes of upper airway obstruction and resultant intermittent hypoxia.
Choice B rationale
Insomnia is not a typical symptom of OSA. While individuals with OSA may experience disrupted sleep, it is usually characterized by excessive daytime sleepiness rather than an inability to sleep.
Choice C rationale
Snoring is a hallmark symptom of OSA. It occurs due to the partial obstruction of the upper airway, which causes vibration of the tissues and results in the sound of snoring.
Choice D rationale
Daytime sleepiness is a common symptom of OSA. This is due to the repeated awakenings throughout the night to resume breathing, which disrupts the sleep cycle and leads to excessive sleepiness during the day.
Choice E rationale
Dyspnea on exertion is not a typical symptom of OSA. While it can occur in severe cases, it is more commonly associated with conditions that affect the heart or lungs, such as heart failure or chronic obstructive pulmonary disease.
Correct Answer is D
Explanation
Choice A rationale
The use of a Passy Muir speaking valve can be important for communication, but it is not the highest priority for discharge teaching.
Choice B rationale
Having the phone number of the healthcare provider to report complications is important, but it is not the highest priority. The patient needs to know how to prevent and recognize complications first.
Choice C rationale
While having emergency personal identification that the patient is unable to speak is important, it is not the highest priority. The patient’s immediate post-operative needs should be addressed first.
Choice D rationale
The ability to perform tracheostomy care is the highest priority for discharge teaching. This is a new and critical skill that the patient must learn to prevent complications, maintain the airway, and manage their own care at home.
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