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

Explanation

Choice A rationale

Frothy sputum is a common finding in patients with left-sided heart failure. This is due to fluid accumulation in the lungs (pulmonary edema), which can cause the sputum to become frothy.

Choice B rationale

Dependent edema is more commonly associated with right-sided heart failure. It occurs due to fluid accumulation in the systemic circulation, leading to swelling in the lower extremities.

Choice C rationale

Nocturnal polyuria can occur in heart failure, but it is not a specific sign of left-sided heart failure.

Choice D rationale

Jugular venous distention is a sign of right-sided heart failure, not left-sided heart failure. It occurs due to increased pressure in the right atrium, leading to visible distention of the jugular veins.

A. “You should have no trouble swallowing fluids.”. B. “It is no longer possible for you to choke on or aspirate food.”. C. “I will add a thickener to your liquids to prevent aspiration.”. D. “Tuck your chin when you swallow so you won’t choke.”.

Correct Answer is D

Explanation

Choice A rationale

After a total laryngectomy, patients may have difficulty swallowing fluids due to changes in the anatomy of the throat.

Choice B rationale

It is not accurate to say that it is no longer possible for the patient to choke on or aspirate food after a total laryngectomy. While the risk of aspiration is reduced because the airway and digestive tract are separated, the patient can still experience choking on food if it is not properly swallowed.

Choice C rationale

Adding a thickener to liquids can help prevent aspiration, but this is typically more relevant for patients with dysphagia or other swallowing disorders, not specifically for patients post- laryngectomy.

Choice D rationale

Tucking the chin when swallowing, also known as the chin-tuck maneuver, can help prevent aspiration by narrowing the entrance to the airway. This can be a useful technique for patients after a laryngectomy.

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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 an older adult patient with left-sided heart failure. What assessment findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a patient who is 9 days postoperative following a total laryngectomy. The nurse removes the patient’s NG tube and initiates oral feedings. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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