A nurse is caring for a client who is postoperative following a tracheostomy and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

Provide humidified oxygen.

Prelubricate the suction catheter tip with sterile saline when suctioning the airway.

Perform chest physiotherapy prior to suctioning.

Hyperventilate the client with 100% oxygen before suctioning the airway.

Answer and Explanation

The Correct Answer is A

a. Provide humidified oxygen: Humidification helps prevent the drying of mucous membranes, making secretions more manageable and less tenacious. This is an acceptable method to thin

secretions in a client with a tracheostomy.

b. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: While lubrication with sterile saline is a common practice during suctioning to reduce trauma to the airway, it does not directly address the tenacity of secretions.

c. Perform chest physiotherapy prior to suctioning: Chest physiotherapy is a technique used to mobilize respiratory secretions, but it may not directly address the tenacity of secretions.

d. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation with 100% oxygen is not a routine practice and may lead to respiratory alkalosis. Providing

humidified oxygen is a more appropriate approach.

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Correct Answer is ["A","C","E"]

Explanation

a. Nausea: Nausea is a common symptom of myocardial infarction and can be associated with autonomic nervous system activation.

b. Orthopnea: Orthopnea, difficulty breathing while lying down, is more commonly associated with heart failure, not necessarily myocardial infarction.

c. Diaphoresis: Profuse sweating or diaphoresis is a common manifestation of myocardial infarction due to sympathetic nervous system activation.

d. Headache: Headache is not a typical symptom of myocardial infarction. However, some individuals may experience atypical symptoms.

e. Tachycardia: Tachycardia (rapid heart rate) is a common response to myocardial infarction and can be associated with sympathetic nervous system stimulation in response to decreased cardiac output.

A. Asthma B. Heart failure C. Aortic valve regurgitation D. Aortic stenosis

Correct Answer is B

Explanation

a. Asthma: While asthma can cause dyspnea and fatigue, it is not typically associated with tachycardia and edema.

b. Heart failure: Heart failure is characterized by symptoms such as dyspnea, fatigue,

tachycardia, and edema. Tachycardia may be a compensatory response to maintain cardiac output, and edema can result from fluid retention.

c. Aortic valve regurgitation: Aortic valve regurgitation may cause symptoms such as dyspnea and fatigue, but it is not typically associated with tachycardia and edema.

d. Aortic stenosis: Aortic stenosis may lead to symptoms such as dyspnea, but tachycardia and edema are not typical features of aortic stenosis.

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A nurse is caring for a client who is postoperative following a tracheostomy and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse in a provider's office is collecting data from a client who reports dyspnea and fatigue.The nurse determines that the client also has tachycardia and edema. Which of the following disorders should the nurse suspect?

Correct Answer is B

Explanation

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