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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Elastic bandages can contain latex, which could potentially cause an allergic reaction. However, latex-free alternatives are available. The client should be advised to specifically look for latex-free bandages. This statement indicates a need for further teaching because using standard elastic bandages might expose the client to latex.
Choice B rationale:
Many dishwashing gloves are made from latex, but there are latex-free alternatives available. The client should be instructed to use latex-free gloves to avoid latex exposure. This statement indicates a need for further teaching as the client might choose latex gloves unintentionally.
Choice C rationale:
Most ink pens do not contain latex. Therefore, using ink pens is generally safe for individuals with latex allergies. This statement does not indicate a need for further teaching.
Choice D rationale:
Balloon latex is a common allergen, and exposure to latex balloons can trigger an allergic reaction in individuals with latex allergies. This statement indicates a need for further teaching because the client should avoid latex balloons and opt for latex-free alternatives to prevent allergic reactions.
Correct Answer is D
Explanation
Choice A rationale
Nitroglycerin oral, sustained-release capsules are not typically taken at the onset of anginal pain. They are usually used to prevent angina attacks rather than to treat them.
Choice B rationale
There is no specific requirement to take the medication with meals.
Choice C rationale
While side effects can be troublesome, patients should not stop taking the medication without consulting their healthcare provider.
Choice D rationale
Nitroglycerin oral, sustained-release capsules should be swallowed whole. They should not be crushed or chewed.
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