The nurse is evaluating a client's need for tracheal suctioning.
The nurse determines that suctioning is needed if which finding is noted?
Respiratory rate of 18 up from 16.
Two hours have elapsed since the patient suctioning.
Congested breath sounds in bilateral lung fields.
Pulse ox level of 95
The Correct Answer is C
Choice A rationale
A respiratory rate of 18 breaths per minute is well within the normal adult range of 12 to 20 breaths per minute. While a slight increase from 16 to 18 might be noted during a physical assessment, it does not provide physiological evidence of airway obstruction or secretion accumulation. Suctioning is an invasive procedure that can cause trauma, hypoxia, and bradycardia, and should only be performed based on specific clinical indications rather than minor fluctuations in a stable respiratory rate.
Choice B rationale
Suctioning should never be performed on a fixed schedule or a routine basis, such as every two hours. Performing tracheal suctioning without a clear clinical indication increases the risk of complications, including tracheal mucosal damage, nosocomial infections, and significant oxygen desaturation. Nursing standards of care dictate that the procedure must be based on a thorough physical assessment of the patient’s airway patency and breath sounds to ensure that the benefits of clearing secretions outweigh the risks.
Choice C rationale
The presence of congested or adventitious breath sounds, such as rhonchi or coarse crackles, during auscultation indicates that secretions are present in the large airways. These secretions can increase airway resistance, interfere with gas exchange, and increase the work of breathing. Auscultating bilateral lung fields and identifying these sounds provides a clear, objective clinical indication that tracheal suctioning is necessary to clear the airway and maintain adequate ventilation and oxygenation for the patient.
Choice D rationale
A pulse oximetry level of 95 percent is generally considered within the acceptable range for most clinical populations, as the standard normal range is 95 percent to 100 percent. While a drop in oxygen saturation can be a late sign of airway obstruction, a reading of 95 percent does not independently justify the need for tracheal suctioning. The nurse must prioritize assessment findings like visible secretions or audible congestion before oxygen levels fall into a hypoxic range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Empyema is the medical term for the accumulation of purulent, pus-filled drainage within the pleural space. This typically occurs as a complication of pneumonia or lung abscess where bacteria invade the pleural cavity. The normal pleural fluid is clear and minimal, but in empyema, white blood cell counts are high and the fluid becomes thick and opaque. The temperature of 102°F or 38.8°C (normal 98.6°F or 37°C) indicates a systemic inflammatory response to this infection.
Choice B rationale
Sputum is mucus that is expectorated from the lower airways through coughing. While sputum can be purulent if an infection like pneumonia is present, it is found within the bronchi and trachea, not the pleural cavity. The fluid aspirated during a thoracentesis comes from the space between the parietal and visceral pleura. Therefore, while both might contain pus, their anatomical locations differ significantly. Sputum is a product of the airway, while empyema is a pleural collection.
Choice C rationale
An embolus is a detached mass, such as a blood clot, air bubble, or fat globule, that travels through the bloodstream and can cause an obstruction. It has no relation to purulent drainage or fluid accumulation in the pleural cavity. The symptoms of an embolus, particularly a pulmonary one, include sudden chest pain and dyspnea, but it would not result in the aspiration of pus via a thoracentesis. It is a vascular pathology rather than an infectious pleural collection.
Choice D rationale
Emphysema is a chronic obstructive pulmonary disease characterized by the destruction of the alveolar walls and permanent enlargement of the air spaces. This leads to air trapping and impaired gas exchange, but it does not involve the accumulation of pus in the pleural cavity. While an emphysematous patient might develop an infection, the term itself refers to structural lung tissue changes. It should not be confused with empyema, which specifically describes the infected fluid found during thoracentesis.
Correct Answer is D
Explanation
Choice D rationale
During a bronchoscopy, a local anesthetic is typically sprayed onto the back of the throat to suppress the gag reflex and allow the scope to pass. It is unsafe for the client to ingest food or fluids until this reflex has fully returned, as there is a high risk of aspiration and choking. The nurse must manually test for the return of the gag reflex using a tongue blade or by observing a successful swallow before allowing oral intake.
Choice A rationale
There is no fixed rule that a client must wait exactly 8 hours after a bronchoscopy before they can eat. The recovery period is entirely dependent on how quickly the local anesthetic wears off and the gag reflex returns. For some patients, this might happen in 2 hours, while for others it may take longer. Setting a rigid 8-hour timeframe is not evidence-based and could unnecessarily delay nutrition or fail to account for a delayed recovery of airway protection.
Choice B rationale
Waiting 24 hours to consume anything other than cold liquids is an unnecessary restriction following a standard bronchoscopy. Cold liquids are sometimes used to soothe a sore throat, but they are not a requirement for a full day. The primary clinical concern is the safety of the airway. Once the gag reflex is present, the client can usually progress to a normal diet as tolerated, provided there are no other surgical complications or specific orders from the physician.
Choice C rationale
It is common for a client to have small amounts of blood-tinged sputum or "pink" secretions for a short time after a bronchoscopy due to tissue irritation or biopsy. While the nurse should monitor for heavy bleeding, the presence of minor streaks of blood is not a contraindication for eating. The determining factor for the safety of oral intake remains the functional status of the swallow and gag reflexes rather than the total absence of any blood in sputum.
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