The nurse performing tracheostomy care will:

raise the head of the bed to high Fowler's position

remove the inner cannula with the ungloved hand

suction tracheostomy before beginning care

clean cannula with gauze and replace and lock

Answer and Explanation

Correct Answer : A,C

A. Raise the head of the bed to high Fowler's position: This promotes optimal lung expansion and drainage, reduces aspiration risk, and facilitates easier tracheostomy care.
B. Remove the inner cannula with the ungloved hand: Sterile technique is required when handling the inner cannula to prevent infection.
C. Suction tracheostomy before beginning care: Suctioning clears secretions and ensures better visibility for care, reducing the risk of aspiration during the procedure.
D. Clean cannula with gauze and replace and lock: The inner cannula should be cleaned per protocol using sterile saline and replaced securely.

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Correct Answer is D

Explanation

A. Pleural friction rub: An adventitious sound that occurs due to inflamed pleural surfaces rubbing against each other during respiration.
B. Rhonchi: A low-pitched, continuous adventitious lung sound typically caused by airway obstruction or secretions.
C. Stridor: A high-pitched adventitious sound caused by upper airway obstruction.
D. Vesicular: A normal breath sound heard over most of the lung fields, characterized by a soft, low-pitched rustling sound.

A. clamp the chest tube and place the patient in high Fowler's position B. immediately turn the patient to the side of the insertion site C. document findings D. check for air leaks in drainage system

Correct Answer is D

Explanation

A. Clamp the chest tube and place the patient in high Fowler’s position: Clamping the tube may cause tension pneumothorax and should be done only with a specific prescription.
B. Immediately turn the patient to the side of the insertion site: This action does not address the source of constant bubbling.
C. Document findings: Bubbling in the suction chamber can be normal, but documenting without further assessment may overlook potential system issues.
D. Check for air leaks in the drainage system: Constant bubbling may indicate an air leak, which requires immediate assessment and correction.

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The nurse performing tracheostomy care will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

Correct Answer is D

Explanation

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)

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

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The nurse is aware that changes occur in the respiratory system after the age of 70 that put the older adult more at risk for respiratory problems. These changes include: (Select all that apply.)

A nurse is nasopharyngeal suctioning an adult patient to remove thick secretions. The nurse will:

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The nurse assists the patient with emphysema into the most beneficial position to facilitate respiration, which is:

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.)