A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

Use medical asepsis when performing the procedure.

Apply suction for 10 seconds.

Advance the catheter 2 cm (0.8 in) after resistance is met.

Withdraw the catheter if the client begins coughing.

Answer and Explanation

The Correct Answer is B

A. Surgical asepsis (sterile technique) should be used for suctioning to prevent infection, not medical asepsis.

B. Applying suction for no longer than 10 seconds is appropriate to prevent hypoxia and trauma to the airway.

C. Advancing the catheter 2 cm after resistance is met is not advised; the catheter should not be forced beyond resistance to avoid injury.

D. The catheter should not be withdrawn if the client begins coughing; instead, it indicates the need for suctioning. If coughing occurs, the nurse should ensure the patient can breathe and may need to suction carefully.

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Correct Answer is B

Explanation

A. Withholding the next dose of warfarin is incorrect. Warfarin takes several days to reach therapeutic levels, and the INR of 1.8 is below the target range (typically 2.0–3.0 for PE treatment). Stopping warfarin is unnecessary.
B. Withholding the heparin infusion is correct. The aPTT is significantly elevated at 98 seconds (therapeutic range: 60–80 seconds for PE treatment), increasing the risk of bleeding. The nurse should pause the heparin infusion and notify the provider for dose adjustment.
C. Preparing to administer vitamin K is incorrect. Vitamin K reverses warfarin effects, but the INR of 1.8 is not dangerously high and does not require reversal.
D. Preparing to administer alteplase is incorrect. Alteplase (a thrombolytic) is used for massive PE with hemodynamic instability, not for a patient already receiving anticoagulation therapy.

A. State the options loudly in a high-pitched voice. B. Ask the client's partner to choose their meal. C. Expect extended time for verbal responses. D. Ask the client to point to items on a picture menu.

Correct Answer is D

Explanation

A. Speaking loudly in a high-pitched voice is not effective for individuals with sensorineural hearing loss, as they may struggle with high-frequency sounds.

B. Asking the client's partner to choose their meal removes the client's autonomy and does not facilitate direct communication.

C. While expecting extended time for verbal responses is considerate, it does not provide a practical solution for meal selection.

D. Asking the client to point to items on a picture menu is an effective way to facilitate communication, allowing the client to express their preferences without relying on verbal communication alone.

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A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices?

Correct Answer is D

Explanation

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A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

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