A nurse is performing tracheostomy care for a patient and plans to remove copious secretions. What actions should the nurse take?

Lubricate the suction catheter tip with sterile saline

Hyperventilate the patient on 100% oxygen prior to suctioning

Perform chest physiotherapy prior to suctioning

Suction two to three times with a 60-second pause between passes

Answer and Explanation

The Correct Answer is D

Choice A rationale

Lubricating the suction catheter tip with sterile saline is not recommended because it can introduce bacteria into the tracheostomy tube and cause infection.

Choice B rationale

Hyperventilating the patient on 100% oxygen prior to suctioning is not necessary and can cause complications such as oxygen toxicity.

Choice C rationale

Performing chest physiotherapy prior to suctioning is not typically done during tracheostomy care. Chest physiotherapy is a separate procedure that involves physical techniques to remove mucus from the respiratory tract.

Choice D rationale

Suctioning two to three times with a 60-second pause between passes is the correct action. This helps to remove secretions effectively without causing hypoxia.

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Correct Answer is ["A","D"]

Explanation

Choice A rationale

In ARDS, impaired carbon dioxide elimination due to shunting can occur. Shunting refers to the diversion of blood from areas of the lung that are ventilated to areas that are not, leading to impaired gas exchange.

Choice B rationale

Decreased pulmonary arterial pressure due to ventilation-perfusion (V/Q) mismatch is not a typical finding in ARDS3.

Choice C rationale

Hypoxemia due to dead space is not a typical finding in ARDS. Dead space refers to areas of the lung that are ventilated but not perfused.

Choice D rationale

Decreased pulmonary compliance due to stiffness is a typical finding in ARDS. The lungs become stiff and less compliant due to the accumulation of fluid and inflammatory cells in the alveoli and interstitial space.

A. Report any eyelid swelling after dosage. B. Repeat the dose in 1 hour if the headache persists. C. Take the medication daily to prevent headaches. D. Thoroughly chew the tablet before swallowing.

Correct Answer is B

Explanation

Choice A rationale

Eyelid swelling is not a common side effect of sumatriptan. If a patient experiences this side effect, they should report it to their healthcare provider.

Choice B rationale

If the headache persists after taking sumatriptan, the patient can repeat the dose in 1 hour. This is a standard instruction for the use of sumatriptan in the treatment of migraine headaches.

Choice C rationale

Sumatriptan is not typically taken daily to prevent headaches. It is used to treat migraines once they have started.

Choice D rationale

Sumatriptan tablets should be swallowed whole, not chewed. Chewing the tablet could result in too much of the drug being released at once.

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A nurse is performing tracheostomy care for a patient and plans to remove copious secretions. What actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?

Correct Answer is ["A","D"]

Explanation

A nurse is instructing a patient who has been newly prescribed sumatriptan tablets for the treatment of migraine headaches.Which instructions should the nurse include?

Correct Answer is B

Explanation

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