A nurse is caring for a client who has a tracheostomy.
The nurse completes an assessment and finds that the client's oxygen saturation is 96
Increased respiratory rate.
Oxygen Saturation of 96
Brisk capillary refill.
Clear breath sounds.
The Correct Answer is A
Choice A rationale
An increased respiratory rate (tachypnea) is often one of the earliest signs of respiratory distress or hypoxia as the body attempts to compensate for inadequate gas exchange. For a patient with a tracheostomy, an elevated rate might indicate that the airway is partially obstructed by secretions or that the patient is struggling to maintain oxygenation despite a currently acceptable saturation level. This finding would require further assessment of the airway and lung sounds.
Choice B rationale
An oxygen saturation of 96 percent is within the normal clinical range (typically 95 to 100 percent) and indicates that the hemoglobin is sufficiently saturated with oxygen. In a patient with a tracheostomy, this value suggests that the current respiratory interventions and airway management are effective. Since this is a normal and stable finding, it would not be a cause for concern or an indication of an immediate respiratory complication.
Choice C rationale
Brisk capillary refill (less than 2 seconds) is a positive clinical sign indicating adequate peripheral perfusion and cardiac output. It suggests that oxygenated blood is effectively reaching the distal tissues. In the context of a tracheostomy assessment, finding brisk capillary refill confirms that the cardiovascular system is not currently compromised by a lack of oxygen, representing a normal and healthy finding rather than a sign of respiratory distress.
Choice D rationale
Clear breath sounds indicate that air is moving freely through the large and small airways without obstruction from fluid, mucus, or bronchoconstriction. In a patient with a tracheostomy, clear lung sounds upon auscultation suggest that the lungs are well-aerated and that there is no significant accumulation of secretions in the lower respiratory tract. This is an expected and desirable outcome of tracheostomy care and does not indicate a problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
The described mechanism refers to bilevel positive airway pressure rather than continuous positive airway pressure. Continuous devices maintain a single fixed pressure level throughout the entire respiratory cycle to splint the upper airway open. By providing constant pressure, the device prevents the collapse of soft tissues in the pharynx. Understanding the difference between constant and variable pressure settings is essential for ensuring the client receives the specific therapeutic intervention prescribed for their apnea.
Choice B rationale
Proper administration of this therapy typically involves a mask that covers the nose or both the nose and mouth to ensure the pressurized air effectively reaches the upper airway. Covering the nose allows the air to create the necessary internal pressure to keep the airway patent during sleep. If the mask is not positioned correctly over the nasal passages, the therapeutic effect is lost, and the client will continue to experience obstructive episodes and oxygen desaturation.
Choice C rationale
A loose fit would lead to significant air leaks, which would compromise the ability of the machine to maintain the required pressure levels in the airway. The mask must have a snug but comfortable seal against the skin to prevent the escape of pressurized air. Inadequate sealing often results in ineffective treatment and can cause eye irritation if the leaking air blows upward. Achieving a proper seal is a fundamental component of client education for successful therapy.
Choice D rationale
This treatment modality is strictly non-invasive and does not require the insertion of any tubes into the trachea or oropharynx. It utilizes a mask and external tubing to deliver room air at a specified pressure. Invasive ventilation is reserved for acute respiratory failure or situations where the client cannot maintain their own airway. Labeling the device as non-invasive helps reduce client anxiety and clarifies that the procedure is simple, external, and manageable at home.
Correct Answer is D
Explanation
Choice A rationale
Neither of these medications is known to significantly alter glucose metabolism or cause hyperglycemia in a way that requires routine monitoring. While some medications can interfere with insulin sensitivity, these specific antituberculosis drugs do not have a primary side effect profile involving the endocrine pancreas. Monitoring sugar levels would only be necessary if the client had a pre-existing condition like diabetes mellitus. Therefore, this test is not a standard requirement for the general population taking this drug regimen.
Choice B rationale
Although these medications are processed by the body and can affect internal organs, they do not have a direct toxic effect on the gallbladder that would necessitate regular ultrasound or functional studies. Gallbladder issues usually manifest as biliary colic or cholecystitis, which are not common adverse reactions to these antibiotics. The primary focus of toxicity for these specific drugs is the parenchymal tissue of the organ responsible for metabolism rather than the storage of bile in the gallbladder.
Choice C rationale
These drugs do not interfere with the production or regulation of thyroid hormones. Hypothyroidism or hyperthyroidism are not recognized side effects of these medications. Routine testing of the hypothalamic-pituitary-thyroid axis is unnecessary unless the client presents with specific symptoms of metabolic dysfunction. Focus should remain on the organs known to be at risk for drug-induced injury. Thyroid function remains stable during typical courses of these medications, and resources should be directed toward more relevant monitoring.
Choice D rationale
Both of these medications are hepatotoxic and can cause significant injury to the cells of the liver. Pyrazinamide and rifampin can lead to drug-induced hepatitis, making it essential to monitor enzymes like alanine aminotransferase and aspartate aminotransferase. Normal ranges are typically 4 to 36 units per liter for ALT and 8 to 33 units per liter for AST. Regular testing allows for early detection of liver damage, ensuring the medication can be adjusted or stopped before permanent organ failure occurs.
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