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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Bronchitis:Bronchitis presents with a productive cough, chest discomfort, and sometimes wheezing, but it does not usually involve facial tenderness, purulent nasal drainage, or worsening nighttime cough due to postnasal drip. Symptoms also tend to resolve in under 2 weeks.

B. Sinusitis:Sinusitis is characterized by persistent cold-like symptoms lasting more than 10 days, purulent nasal discharge, headache, facial pain or tenderness, and a cough that worsens at night due to postnasal drainage. This description fits the presentation of pediatric sinusitis.

C. Asthma:Asthma presents with wheezing, shortness of breath, and episodic coughing, especially at night or during exertion. It does not cause purulent nasal drainage, facial tenderness, or prolonged cold symptoms, which point more toward sinus infection.

D. Allergic rhinitis:Allergic rhinitis causes sneezing, clear nasal discharge, itchy eyes, and nasal congestion, but not purulent drainage or facial pain. Symptoms are usually triggered by allergens and are not typically accompanied by fever or thick mucus.

Correct Answer is ["0.5"]

Explanation

Calculation:

Desired dose = 5,000 units.

Available concentration = 10,000 units/mL.

Calculate the volume to administer.

Volume (mL) = Desired dose (units) / Available concentration (units/mL)

= 5,000 units / 10,000 units/mL

= 0.5 mL..

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A nurse is caring for a patient with a tracheostomy. What should the nurse do to determine the patient needs suctioning?

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Naxlex Comprehensive Predictor Exams

A child has had cold symptoms for more than 2 weeks, a headache, nasal congestion with purulent nasal drainage, facial tenderness, and a cough that increases during sleep. The nurse recognizes that these symptoms are characteristic of which respiratory condition?

Correct Answer is B

Explanation

The healthcare provider orders 5,000 units of heparin subcutaneously every 8 hours. The vial label reads heparin sodium 10,000 units/mL. How many milliliters should the nurse administer per dose? (DO NOT ROUND. LABEL CORRECTLY TO RECEIVE CREDIT)

Correct Answer is ["0.5"]

Explanation

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