After suctioning a client who has an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?

Clear breath sounds on auscultation.

Increased respiratory rate.

Decreased oxygen saturation.

Presence of wheezing.

Answer and Explanation

The Correct Answer is A

Choice A reason: Clear breath sounds indicate effective suctioning, as it removes secretions obstructing the airway, improving ventilation. This aligns with the goal of endotracheal suctioning to maintain airway patency, ensuring adequate oxygenation and reducing infection risk, per critical care and respiratory management protocols in nursing practice.

Choice B reason: Increased respiratory rate suggests respiratory distress, indicating ineffective suctioning. Clear breath sounds confirm secretion removal, ensuring airway patency. A rising rate may reflect persistent obstruction or hypoxia, requiring further intervention, per respiratory assessment and critical care standards for endotracheal tube management in nursing.

Choice C reason: Decreased oxygen saturation indicates ineffective suctioning, as secretions likely remain, impairing oxygenation. Clear breath sounds confirm airway clearance, improving gas exchange. Low saturation requires immediate reassessment, per oxygenation monitoring and critical care protocols for clients with endotracheal tubes in nursing practice.

Choice D reason: Presence of wheezing suggests airway narrowing or persistent secretions, indicating ineffective suctioning. Clear breath sounds demonstrate successful secretion removal, ensuring unobstructed airflow. Wheezing requires further intervention, per respiratory assessment and airway management standards in critical care nursing for intubated clients.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Going to the ER for glucose is unnecessary unless hypoglycemia or ketoacidosis is confirmed. Type 1 diabetes with nausea risks hyperglycemia from stress hormones like cortisol. Monitoring glucose and fluids manages the condition at home, preventing escalation unless severe symptoms arise, making this instruction premature.

Choice B reason: Drinking regular cola introduces high sugar, risking hyperglycemia in type 1 diabetes, where insulin deficiency impairs glucose uptake. Stress from illness elevates glucose via glucagon. Monitoring with non-sugar fluids prevents dehydration and ketoacidosis, making this advice dangerous and ineffective for diabetes management.

Choice C reason: Monitoring blood glucose and drinking fluids is critical in type 1 diabetes during illness. Nausea reduces intake, and stress hormones raise glucose, risking ketoacidosis. Frequent checks guide insulin adjustments, and fluids prevent dehydration, maintaining metabolic stability, addressing the physiological needs of insulin deficiency and infection.

Choice D reason: Avoiding insulin risks diabetic ketoacidosis, as type 1 diabetes requires basal insulin despite nausea. Illness increases glucose via stress hormones, even without food. Monitoring allows tailored dosing, preventing hyperglycemia, making this instruction harmful, as it ignores ongoing insulin needs for metabolic control.

A. Administer an IV narcotic analgesic. B. Adjust compression device until client is comfortable. C. Turn the client to a left side-lying position. D. Assess the femoral PCI access site for a hematoma.

Correct Answer is D

Explanation

Choice A reason: Administering an IV narcotic masks pain without addressing its cause. Pain at the PCI site may indicate hematoma or arterial injury, common post-PCI due to vessel trauma and tirofiban’s antiplatelet effects. Assessing the site identifies bleeding, critical to prevent complications like hemorrhage before providing analgesia.

Choice B reason: Adjusting the compression device without assessment risks worsening a hematoma, as excessive pressure impairs flow, while insufficient pressure fails to control bleeding. Tirofiban increases bleeding risk. Assessing for hematoma ensures proper management, preventing vascular complications, making adjustment premature without confirming the pain’s cause.

Choice C reason: Turning to a left side-lying position does not address PCI site pain, potentially from hematoma or arterial injury. Post-PCI, supine positioning minimizes site stress. Assessing for hematoma, exacerbated by tirofiban’s anticoagulation, is critical to detect bleeding, preventing complications like retroperitoneal hemorrhage over positional changes.

Choice D reason: Assessing the femoral PCI site for hematoma is essential, as pain may indicate bleeding, common post-PCI with tirofiban’s platelet inhibition. Hematoma can compress vessels, causing ischemia or rupture, requiring urgent intervention like compression or surgery. This addresses the pathophysiological risk, ensuring vascular stability and patient safety.

View Question and Answer

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

After suctioning a client who has an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with type 1 diabetes mellitus calls the home care nurse and reports taking a morning dose of 70/30 insulin before realizing they have a stomach virus and are now unable to eat breakfast due to nausea. Which initial instruction should the nurse provide?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. Which should the nurse do next? (Select all that apply)

At 0800, the practical nurse (PN) reports to the registered nurse (RN) that a client’s blood pressure is 140/90 mm Hg. When the RN arrives to administer the 0900 antihypertensive medication, the client is oriented but lethargic, pale, and diaphoretic. Which action should the RN implement first?

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

Which data warrants the most immediate intervention by the nurse for a client with diabetes insipidus (DI)? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)].

An older adult male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. Which action should the nurse implement?

The nurse orients a client with depression to a new room on the mental health unit. The client states, “It seems strange that I don’t have a television (TV) in my room.” Which statement is best for the nurse to provide?

A client with gastroesophageal reflux disorder (GERD), who has been self-medicating with famotidine for the past week, is admitted to the acute care center because the symptoms have worsened. The nurse should anticipate which treatment?