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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While it’s possible for a virus to reactivate in the body, this is not typically the case with the common cold. The common cold is a viral infection primarily in the nose, with most people recovering in seven to ten days.
Choice B rationale
While it’s true that cold season tends to end as the weather warms up, this doesn’t address the patient’s concern about their repeated colds. It’s important to note that colds are caused by viruses, which can be spread year-round, although they are more common in the colder months.
Choice C rationale
This is the correct answer. The common cold is indeed a virus that can be spread by a person two days before they experience any symptoms. This means that people can spread the virus before they know they’re sick, which can make it difficult to avoid catching a cold.
Choice D rationale
While wearing a mask can help prevent the spread of viruses, it’s not typically necessary for someone who is simply sensitive to colds. Masks are more commonly recommended for people who are already sick to prevent them from spreading the virus, or for people who are at high risk of serious complications from the cold.
Correct Answer is B
Explanation
Choice A rationale
While it’s important to reassure the patient, saying “It’s uncertain if your smoking led to the cancer” might be misleading. Smoking is a major risk factor for lung cancer, but it’s also true that not everyone who smokes gets lung cancer, and not everyone who gets lung cancer has smoked.
Choice B rationale
This response validates the patient’s feelings and opens up a dialogue about their specific fears. It allows the nurse to provide targeted education and reassurance.
Choice C rationale
Asking “Do you feel guilty because you used to smoke?” might make the patient feel more guilty or judged. It’s better to provide support and understanding.
Choice D rationale
While it’s true that fear is a normal reaction and that the healthcare team is there to support the patient, this response doesn’t address the patient’s specific concerns or feelings of guilt.
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