A nurse is reinforcing discharge teaching with the partner of a client who requires tracheal suctioning. Which of the following statements by the partner indicates an understanding of the teaching?

"I will wrap the suction catheters in a clean towel to be used again at a later time."

"I will set the suction pressure dial between 80 and 120."

"I will suction for less than 15 seconds while inserting the suction catheter."

"I will suction the mouth before inserting the suction catheter into the tracheostomy."

Answer and Explanation

The Correct Answer is B

Choice A Reason:

The statement “I will wrap the suction catheters in a clean towel to be used again at a later time” is incorrect. Suction catheters should be disposed of after each use to prevent infection. Reusing catheters, even if wrapped in a clean towel, can introduce bacteria into the tracheostomy site, leading to potential infections.

Choice B Reason:

The statement “I will set the suction pressure dial between 80 and 120” is correct. The recommended suction pressure for adults is typically between 80 and 120 mmHg. This range is sufficient to effectively clear secretions without causing trauma to the tracheal mucosa. Setting the suction pressure within this range ensures safe and effective suctioning.

Choice C Reason:

The statement “I will suction for less than 15 seconds while inserting the suction catheter” is incorrect. Suctioning should be performed intermittently and for no longer than 10-15 seconds at a time. However, suctioning should not occur while inserting the catheter. Suction should be applied only while withdrawing the catheter to minimize trauma to the tracheal mucosa.

Choice D Reason:

The statement “I will suction the mouth before inserting the suction catheter into the tracheostomy” is incorrect. Suctioning the mouth before the tracheostomy can introduce oral bacteria into the tracheostomy site, increasing the risk of infection. The correct procedure is to suction the tracheostomy first and then the mouth if needed.

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Correct Answer is A

Explanation

Choice A reason: Oxybutynin is an anticholinergic drug that relaxes the muscles of the bladder and reduces spasms, urgency, and frequency of urination. It is used to treat overactive bladder and urinary incontinence.

Choice B reason: Oxybutynin does not increase tissue perfusion in the lungs, as it has no effect on the respiratory system. It can actually cause dry mouth, nasal congestion, and blurred vision as side effects.

Choice C reason: Oxybutynin does not increase venous return to the heart, as it has no effect on the cardiovascular system. It can actually cause tachycardia, palpitations, and hypertension as side effects.

Choice D reason: Oxybutynin does not relax the muscles of the colon, as it has no effect on the gastrointestinal system. It can actually cause constipation, nausea, and abdominal pain as side effects.

Click and drag to move

A. Hyperactive deep tendon reflexes B. Hypoactive bowel sounds C. Positive Chvostek's sign D. Lethargy

Correct Answer is C

Explanation

Choice A: This is incorrect because hyperactive deep tendon reflexes are not associated with low serum calcium levels. Hyperactive deep tendon reflexes can indicate hypomagnesemia, hyperthyroidism, or spinal cord injury.

Choice B: This is incorrect because hypoactive bowel sounds are not associated with low serum calcium levels. Hypoactive bowel sounds can indicate ileus, peritonitis, or opioid use.

Choice C: This is correct because positive Chvostek's sign is associated with low serum calcium levels. Positive Chvostek's sign is a facial muscle spasm that occurs when tapping on the cheek near the ear. It indicates hypocalcemia, which can be caused by hemodialysis, renal failure, or parathyroid dysfunction.

Choice D: This is incorrect because lethargy is not associated with low serum calcium levels. Lethargy can indicate hypercalcemia, dehydration, hypoglycemia, or infection.

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A nurse is reinforcing discharge teaching with the partner of a client who requires tracheal suctioning. Which of the following statements by the partner indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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