A postoperative client with a tracheostomy tube in place suddenly begins have noisy, bubbly sounding respirations. What action should the nurse take first?

Suction the tracheostomy

Change the tracheostomy tube

Notify the healthcare provider

Change the tracheostomy dressing

Do a head to toe assessment

Answer and Explanation

The Correct Answer is A

A. Suctioning the tracheostomy is the priority action to clear secretions, which is likely the cause of the noisy, bubbly respirations. This can help the client breathe more easily.
B. Changing the tracheostomy tube is only necessary if the tube is obstructed or malfunctioning, and suctioning is generally the first step.
C. Notifying the healthcare provider may be needed if suctioning is ineffective or if complications persist, but immediate intervention is required.
D. Changing the tracheostomy dressing does not address the respiratory noise or potential secretion buildup.
E. A head-to-toe assessment may be needed, but the immediate concern is clearing the airway obstruction.

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

Explanation

A. Edema is a common finding in heart failure due to fluid retention.
B. Shortness of breath occurs due to fluid accumulation in the lungs, common in heart failure.
C. Increased appetite is not typical in heart failure; decreased appetite is more common.
D. Weight gain due to fluid retention is more common in heart failure, rather than extreme weight loss.
E. Jugular vein distention is a classic sign of right-sided heart failure due to increased central venous pressure.

A. "Poor electric impulse conduction through the heart" B. "Turbulent blood flow through the heart valves" C. "Enlargement of the left ventricle." D. "Weak contraction of the atria." E. "Long-term systemic hypertension."

Correct Answer is B

Explanation

A. Poor electrical impulse conduction may lead to arrhythmias but does not cause a murmur.
B. A heart murmur is caused by turbulent blood flow, often through narrowed or leaking valves, creating an abnormal heart sound.
C. Left ventricular enlargement can contribute to other cardiac issues but does not directly cause murmurs.
D. Weak atrial contractions may lead to decreased cardiac output but not necessarily to a murmur.
E. While hypertension can affect the heart, it is not the direct cause of a murmur.

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A postoperative client with a tracheostomy tube in place suddenly begins have noisy, bubbly sounding respirations. What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

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

Explanation

A client asks the nurse to describe what causes a murmur. What would be the correct response by the nurse?

Correct Answer is B

Explanation

Which of the following scenarios gives the most absolute confirmation client learning has taken place? Select all that apply.

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