A patient with a tracheostomy has thick, tenacious secretions. In order to maintain the airway, what is the most appropriate action for the nurse to include?
Tracheal suctioning
Nasotracheal suctioning
Orotracheal suctioning
Oropharyngeal suctioning
The Correct Answer is A
Rationale:
A. Tracheal suctioning is the most appropriate intervention for a patient with a tracheostomy and thick, tenacious secretions. It directly clears the airway through the tracheostomy tube.
B. Nasotracheal suctioning is used for patients without a tracheostomy to access the lower airway through the nasal passage.
C. Orotracheal suctioning is also intended for patients without a tracheostomy and is more invasive.
D. Oropharyngeal suctioning clears secretions from the mouth and throat only, not the trachea, and is insufficient for maintaining a tracheostomy airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Asking the patient to cough is appropriate if the tube has entered the airway, but it is not the first action when resistance is encountered.
B. Withdrawing the tube to the nasopharynx is the correct action. Resistance usually means the tube has hit an obstruction (e.g., nasal passage, turbinates, or esophagus). Pulling back allows for repositioning and reinsertion without causing trauma.
C. Encouraging the patient to swallow is helpful after the tube has passed the oropharynx but not when resistance is met during early insertion.
D. Hyperextending the neck makes passage into the esophagus more difficult; flexion of the neck is recommended during insertion.
Correct Answer is D
Explanation
Rationale:
A. The position of the forearm can affect flow if the IV site becomes kinked or compressed.
B. The height of the IV bag/container directly affects gravity flow—the higher the bag, the faster the flow.
C. The relationship of angiocath size to the vein can influence resistance and flow rate.
D. The patient’s weight and height do not affect the gravity flow rate of an IV infusion, making this the correct exception.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.