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 ["B","C","E"]

Explanation

Choice A rationale

Albuterol does not directly decrease coughing episodes. Coughing can be a symptom of an underlying condition like asthma, which albuterol can help manage by relaxing the muscles around the airways. However, the medication itself does not have a direct effect on coughing.

Choice B rationale

Albuterol helps prevent wheezing by relaxing the muscles around the airways, allowing them to open up and making it easier to breathe. Wheezing is a common symptom of conditions like asthma, which albuterol is often used to treat.

Choice C rationale

Albuterol works by opening the airways of the lungs, making it easier to breathe. It does this by relaxing the muscles around the airways, allowing more air to flow into the lungs.

Choice D rationale

Albuterol does not stimulate the flow of mucus. While it can help manage symptoms of conditions like asthma, it does not have a direct effect on mucus production.

Choice E rationale

Albuterol does not directly reduce inflammation. It works by relaxing the muscles around the airways, which can help alleviate symptoms of conditions characterized by inflammation, such as asthma. However, the medication itself does not have anti-inflammatory properties.

A. “Have you experienced any nausea or vomiting with your headache?” B. “Are the lights in this room bothering you?” C. “Have you noticed any confusion or clouded thinking?” D. “Did you feel weak before the headache started or do you feel weak now?”

Correct Answer is A

Explanation

Choice A rationale

Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help in assessing the severity of the migraine and planning appropriate interventions.

Choice B rationale

Sensitivity to light, also known as photophobia, is a common symptom of migraines. However, the presence of this symptom alone may not provide a comprehensive understanding of the patient’s condition.

Choice C rationale

While confusion or clouded thinking can occur with migraines, they are not as common as other symptoms such as nausea, vomiting, and sensitivity to light.

Choice D rationale

Feeling weak before the headache starts or currently feeling weak can be associated with migraines, but they are not the most common symptoms.

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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 caring for a patient who wants to know how albuterol aids his breathing. What should the nurse’s response be? (Select all that apply)

Correct Answer is ["B","C","E"]

Explanation

A patient with a history of migraines is at the clinic complaining of a throbbing headache. Which of the followingQuestions should the nurse include in the assessment?

Correct Answer is A

Explanation

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