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.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Loop the tubing of the chest tube on the client's bed: Looping can create kinks or blockages, impeding drainage and increasing the risk of complications.
B. Place the chest tube drainage system above the level of the client's heart: This would prevent gravity drainage, leading to fluid accumulation in the pleural space.
C. Strip the client's chest tube every 2 hrs: Stripping can create high negative pressure, damaging lung tissue.
D. Tape the connections on the client's chest tube: Securing all connections with tape helps maintain a closed system and prevents air leaks.

A. Toe B. Skin fold C. Earlobe D. Finger

Correct Answer is C

Explanation

A) Toe. Thickened toenails and edema make this site unreliable for accurate readings.
B) Skin fold. Skin folds are not recommended for pulse oximetry measurements due to poor contact and inconsistent readings.
C) Earlobe. The earlobe is a preferred site in cases of peripheral edema or thickened nails because it has good perfusion and provides reliable readings.
D) Finger. Edema in the hands compromises the accuracy of finger pulse oximetry measurements.

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The nurse performing tracheostomy care will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has a chest tube. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

Correct Answer is C

Explanation

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

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