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 C

Explanation

a. Hyperactive bowel sounds: Shock is more likely to be associated with decreased bowel sounds rather than hyperactive bowel sounds.

b. Increased urine output: In the early stages of shock, there may be an increase in urine output as the body attempts to compensate. However, as shock progresses, renal perfusion decreases,

leading to decreased urine output.

c. Hypotension: Hypotension is a key indicator of shock. In shock, there is insufficient blood flow to meet the body's oxygen and nutrient needs, resulting in a drop in blood pressure.

d. Bradycardia: Shock typically leads to an increased heart rate (tachycardia) as the body tries to compensate for decreased cardiac output. Bradycardia is not a typical finding in the early stages of shock.

A. Serum chloride 99 mEq/L B. Serum calcium 10.5 mg/dL C. Serum potassium 5.2 D. Serum sodium 140 mEq/L.

Correct Answer is C

Explanation

a. Serum chloride 99 mEq/L: Serum chloride within the reference range is not an adverse effect of spironolactone.

b. Serum calcium 10.5 mg/dL: Serum calcium within the reference range is not an adverse effect of spironolactone.

c. Serum potassium 5.2: Spironolactone is a potassium-sparing diuretic, and an elevated serum potassium level is an adverse effect that requires monitoring. The nurse should assess for

hyperkalemia.

d. Serum sodium 140 mEq/L: Serum sodium within the reference range is not an adverse effect of spironolactone.

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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

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