A nurse is caring for a client who has a tracheostomy tube.
Upon data collection, the nurse observes the client is restless and hears crackles in the lungs.
Which of the following interventions should the nurse take?
Instill saline into the tubing.
Check the cuff pressure.
Perform suctioning.
Increase the humidification.
The Correct Answer is C
Choice A rationale
Instilling saline into the tubing is not recommended as it increases infection risks and does not clear secretions effectively. It is contraindicated in tracheostomy care and can harm the patient’s respiratory system.
Choice B rationale
Checking the cuff pressure is essential to prevent complications like tracheal injury or air leaks. However, it does not directly alleviate restlessness or crackles in the lungs caused by secretions.
Choice C rationale
Performing suctioning removes secretions from the tracheostomy tube and airways, improving oxygenation and reducing lung crackles. It is the most effective immediate intervention for this scenario.
Choice D rationale
Increasing humidification prevents secretion thickening but does not address accumulated secretions already causing crackles and respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Preferring not to look at the stoma site indicates difficulty accepting the altered body image and is often associated with feelings of denial or embarrassment. Acceptance is typically demonstrated through engagement in self-care activities.
Choice B rationale
Associating acceptance with decreased sexual activity is inaccurate, as altered body image does not directly predict changes in sexual behavior. Acceptance is better indicated by the client’s emotional adjustment and active participation in care.
Choice C rationale
Participating in ostomy care demonstrates acceptance by showing the client is willing to engage in managing their new body function. This indicates an understanding and integration of the change into their daily life.
Choice D rationale
Denying feelings of sadness about the ostomy may reflect emotional suppression rather than true acceptance. Acceptance involves acknowledging emotions and adapting positively to the new situation. .
Correct Answer is A
Explanation
Choice A rationale
The client wearing a mask during transport helps minimize the risk of transmitting infectious droplets to others. It is the most effective precaution to uphold droplet isolation protocols and ensure safe transport in healthcare settings.
Choice B rationale
The nurse wearing a mask is standard PPE practice, but it does not address the primary goal of preventing the client from spreading infectious droplets during transportation. The client must be the primary focus of this preventive measure.
Choice C rationale
Wearing a gown is unnecessary for droplet precautions during transport. Droplet isolation measures primarily target respiratory secretions, and gowns are not effective for minimizing respiratory droplet dissemination.
Choice D rationale
Similar to Choice C, the nurse wearing a gown is not a droplet precaution strategy related to transportation. The focus remains on respiratory measures, specifically masking the client.
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