The nurse is performing tracheostomy care for a client who underwent a laryngectomy for laryngeal cancer. During the procedure, the client begins to cough and is unable to clear the secretions. After the nurse suctions the airway, which finding indicates the intervention was effective?

Absence of coarse crackles.

Increase in respiratory rate.

Increase in breath sounds.

Absence of fine crackles.

Answer and Explanation

The Correct Answer is A

A)   Correct - The absence of coarse crackles indicates that the airway has been cleared of secretions effectively, and the lung sounds are clearer.
B)   Incorrect - An increase in respiratory rate could indicate distress rather than the effectiveness of the intervention.
C)   Incorrect - An increase in breath sounds may not necessarily indicate the effectiveness of the intervention, as the quality of breath sounds matters more than the increase.
D)   Incorrect - The absence of fine crackles might not directly indicate the effectiveness of the intervention, as other factors can influence lung sounds.

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Correct Answer is C

Explanation

Croup is a respiratory infection that causes inﬂammation and narrowing of the airway, resulting in a barking cough, hoarseness, and stridor. The PN should monitor the child's oxygen saturation level via pulse oximetry, as it can indicate the severity of the airway obstruction and the need for supplemental oxygen or other interventions.

A. "Tomorrow I will talk to that nurse about how you were treated last night." B. "I am happy that you are getting better and will be able to go home." C. "I am glad you like me. Which nurse was acting aloof to you?" D. "What did the night nurse do that makes you think she is aloof?"

Correct Answer is D

Explanation

A) Incorrect- This response might address the client's concern but doesn't directly address her dichotomous thinking or provide immediate therapeutic communication.
B) Incorrect- While showing happiness for the client's improvement is positive, this response does not address the client's behavior or engage with her dichotomous tendency.
C) Incorrect- This response acknowledges the client's liking but doesn't address the dichotomous thinking pattern or provide an effective therapeutic response.
D) Correct- answering this question encourages the client to express her concerns and perceptions, fostering communication. This approach acknowledges the client's feelings and provides an opportunity for her to discuss the issue, potentially leading to a productive conversation.

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The nurse is performing tracheostomy care for a client who underwent a laryngectomy for laryngeal cancer. During the procedure, the client begins to cough and is unable to clear the secretions. After the nurse suctions the airway, which finding indicates the intervention was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

The nurse is performing a functional assessment on an older client who lost five pounds (2.27 Kg) of weight since the last visit 12 weeks ago, and who reports a decrease in energy and appetite. Which action should the nurse include during the assessment?

Find patient data below. Exhibits here What actions should the nurse plan for the rest of the shift? Select all that apply.

An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?

When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago." Which action should the PN implement first?

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?" Which action should the practical nurse (PN) implement?