A nurse is caring for a patient with a tracheostomy. What should the nurse do to determine the patient needs suctioning?
determining the last time the patient was suctioned.
auscultating the breath sounds.
monitoring the rate of respirations.
examining the character of the sputum.
The Correct Answer is B
A. Determining the last time the patient was suctioned: The timing of previous suctioning is not a reliable indicator of current need. Suctioning is a clinical decision based on assessment, not a fixed schedule or time interval.
B. Auscultating the breath sounds: Listening to lung sounds helps detect the presence of secretions, such as crackles or rhonchi, indicating airway obstruction. This is the most direct and effective method to assess the need for suctioning in a tracheostomized patient.
C. Monitoring the rate of respirations: An increased respiratory rate can suggest respiratory distress but is non-specific and may result from various causes, including anxiety, fever, or pain. It does not definitively indicate the presence of secretions.
D. Examining the character of the sputum: Sputum characteristics provide information about infection or hydration status, but unless secretions are visibly present or obstructing the airway, they don’t confirm the immediate need for suctioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Determining the last time the patient was suctioned:The timing of previous suctioning is not a reliable indicator of current need. Suctioning is a clinical decision based on assessment, not a fixed schedule or time interval.
B. Auscultating the breath sounds:Listening to lung sounds helps detect the presence of secretions, such as crackles or rhonchi, indicating airway obstruction. This is the most direct and effective method to assess the need for suctioning in a tracheostomized patient.
C. Monitoring the rate of respirations:An increased respiratory rate can suggest respiratory distress but is non-specific and may result from various causes, including anxiety, fever, or pain. It does not definitively indicate the presence of secretions.
D. Examining the character of the sputum:Sputum characteristics provide information about infection or hydration status, but unless secretions are visibly present or obstructing the airway, they don’t confirm the immediate need for suctioning.
Correct Answer is A
Explanation
A. Place a mask over the patient's nose and mouth:When a patient with active TB leaves the isolation room, they must wear a surgical mask to prevent airborne transmission. This protects others from inhaling Mycobacterium tuberculosisin shared spaces.
B. Notify the x-ray department that the test must be cancelled:There is no need to cancel the diagnostic test. Proper precautions like masking the patient enable safe transport and continuation of necessary medical care.
C. Place a gown and gloves on the patient:Gowns and gloves are used for contact precautions, not airborne. TB transmission is airborne, and a surgical mask is the appropriate protective measure for the patient not gowning or gloving.
D. Call the x-ray department to make sure the waiting room is empty:While minimizing exposure is ideal, it is not sufficient or necessary if the patient wears a mask. Standard protocol centers on masking the patient and notifying departments of isolation status, not on room occupancy control.
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