The multiple causes for hypoxia include: (Select all that apply.)

aspirated vomit

pulmonary fibrosis

hiccoughs

high altitude

Answer and Explanation

Correct Answer : A,B,D

A. Aspirated vomit: Can obstruct the airway or cause aspiration pneumonia, reducing oxygenation.
B. Pulmonary fibrosis: Scarring of lung tissue impairs gas exchange, leading to hypoxia.
C. Hiccoughs: Not associated with hypoxia; they are an involuntary diaphragmatic spasm.
D. High altitude: Decreased atmospheric oxygen levels can result in hypoxia.

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Correct Answer is D

Explanation

A. Perform tracheostomy care for the client every 4 hr: Tracheostomy care is performed based on the assessment of the need for cleaning and secretion management rather than a fixed time schedule.
B. Place the client in a lateral recumbent position prior to tracheostomy care: This position does not facilitate optimal visualization of the tracheostomy site. The Fowler's or semi-Fowler's position is preferred.
C. Clean the tracheostomy stoma with a chlorhexidine solution: Chlorhexidine is too harsh for mucosal surfaces and can cause irritation. Normal saline is recommended for cleaning.
D. Preoxygenate the client for 10 seconds prior to tracheostomy care: Preoxygenation for at least 30 to 60 seconds is recommended to prevent hypoxia during suctioning.

A. Check for secretion clearance. B. Check the function of the suction catheter. C. Don sterile gloves. D. Adjust the suction to 120 to 150 mm Hg. E. Insert the catheter without suction. F. Apply intermittent suction while rotating the catheter G. Hyperoxygenate the client.

Correct Answer is B,C,D,G,E,F,A

Explanation

Check the function of the suction catheter: Ensures the catheter is functioning properly before starting the procedure.

Don sterile gloves: Maintains asepsis during the suctioning procedure.

Adjust the suction to 120 to 150 mm Hg: Proper suction pressure prevents mucosal trauma.

Hyperoxygenate the client: Prevents hypoxia during the suctioning process.

Insert the catheter without suction: Prevents trauma to mucosa by reducing suction on insertion.

Apply intermittent suction while rotating the catheter: Effectively clears secretions while minimizing tissue damage.

Check for secretion clearance: Ensures the airway is clear and the procedure was effective.

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The multiple causes for hypoxia include: (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is B,C,D,G,E,F,A

Explanation

A patient has collapsed and cannot be aroused by asking loudly, "Are you okay?" The next action should be to:

Which of the following is not considered an adventitious lung sound upon auscultation:

The nurse recognizes that a postoperative patient who can breathe independently but has trouble maintaining an airway because of the tongue falling back into the throat would be best benefitted by a(n)

The multiple causes for hypoxia include: (Select all that apply.)

A nurse is collecting data from a client who has a respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse expect?

The nurse performing tracheostomy care will:

The nurse caring for a patient with a disposable chest drainage system can promote effective tube function and patient safety by:

A patient requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should: