The nurse is setting up the environment for tracheal suction on a newly postoperative tracheostomy patient. Which action(s) should the nurse perform? (Select 4 correct answers)

Perform suction with sterile supplies.

Auscultate lungs for retained secretions.

Don clean gloves and lift out catheter and connect to suction.

Wash hands and open sterile suction kit.

Inform the patient about the procedure.

Answer and Explanation

Correct Answer : A,B,D,E

A. Perform suction with sterile supplies: Sterile technique is essential when suctioning a tracheostomy to prevent introducing pathogens into the lower airway. Sterile supplies and gloves help reduce the risk of infection in this direct airway access point.

B. Auscultate lungs for retained secretions: Before suctioning, the nurse should assess for signs that suctioning is needed, such as abnormal breath sounds (e.g., crackles, rhonchi) that indicate secretion buildup in the airways.

C. Don clean gloves and lift out catheter and connect to suction: Clean gloves are insufficient for the suctioning procedure. This is an invasive technique involving direct access to the lower airway, requiring sterile gloves and equipment to prevent infection.

D. Wash hands and open sterile suction kit: Hand hygiene is a fundamental part of infection control. Opening the sterile suction kit properly maintains the sterility of equipment needed for the procedure.

E. Inform the patient about the procedure: Providing a brief explanation prepares the patient, reduces anxiety, and promotes cooperation. Even if the patient is nonverbal, communication is part of professional and ethical nursing care.

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Correct Answer is B

Explanation

A. "We will do a simple blood test.A blood test may show signs of infection, such as elevated white blood cells, but it cannot confirm RSV. It is not a specific or reliable method for diagnosing respiratory syncytial virus in infants.

B. "We will swab your child’s nose and send the specimen for testing.Nasopharyngeal swabs are commonly used to detect RSV using antigen detection or polymerase chain reaction (PCR) testing. The procedure is non-invasive, and highly specific for diagnosing RSV.

C. "We will have to sedate your child and do a CT scan of his chest."CT scans are not used to diagnose RSV and carry unnecessary risk, especially with sedation in infants. Imaging is reserved for complicated or atypical cases and does not confirm viral etiology.

D. “There is no specific test for RSV."There are several reliable tests available for detecting RSV, including rapid antigen tests and PCR from nasal secretions. Accurate testing is important for confirming diagnosis and preventing transmission.

A. Complaints of frequent foul-smelling stool B. Finger clubbing C. "Salty" skin surfaces D. Extreme thirst E. Thick sputum production

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

Explanation

A. Complaints of frequent foul-smelling stool:Clients with cystic fibrosis often have pancreatic enzyme deficiencies, leading to malabsorption and steatorrhea frequent, bulky, and foul-smelling stools that contain undigested fat.

B. Finger clubbing:Clubbing is a result of chronic hypoxia and is a common finding in patients with long-standing pulmonary disease such as cystic fibrosis. It reflects poor oxygenation over time.

C. "Salty" skin surfaces:One of the hallmark signs of cystic fibrosis is salty-tasting skin due to excessive chloride in sweat. It is often noted by parents and used in the diagnosis through sweat chloride testing.

D. Extreme thirst:While dehydration can occur in CF, especially in hot weather, extreme thirst is not a common or defining symptom. It is more typically associated with conditions like diabetes mellitus or insipidus.

E. Thick sputum production:CF leads to thick, sticky mucus production in the lungs and airways. This results in chronic cough, recurrent infections, and difficulty clearing secretions, all of which are prominent clinical features.

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The nurse is setting up the environment for tracheal suction on a newly postoperative tracheostomy patient. Which action(s) should the nurse perform? (Select 4 correct answers)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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