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 A

Explanation

A. Continue to monitor the client: A rise in the water seal with inspiration and fall during expiration (tidaling) is normal in a functioning chest tube system and indicates proper lung expansion.
B. Clamp the chest tube near the water seal: Clamping the tube can cause tension pneumothorax and is not appropriate unless specifically instructed by a provider.
C. Reposition the client and recheck the chamber: Repositioning is unnecessary unless there are signs of obstruction or complications.
D. Add water to the chamber: Water addition is only required if the water level falls below the recommended amount, not in response to normal tidaling.

A. A nonrebreather mask should fit snugly over a client's face. B. The reservoir bag on a nonrebreather mask should collapse with exhalation. C. A nonrebreather mask dries a client's mucous membranes. D. Use a non rebreather mask to deliver low-flow oxygen.

Correct Answer is A

Explanation

A) A nonrebreather mask should fit snugly over a client's face. A proper fit ensures effective oxygen delivery and prevents room air from entering the mask.
B) The reservoir bag on a nonrebreather mask should collapse with exhalation. The reservoir bag should not completely collapse. If it does, the oxygen flow may be inadequate.
C) A nonrebreather mask dries a client's mucous membranes. While high-flow oxygen delivery systems can dry mucous membranes, this is not specific to non rebreather masks.
D) Use a non rebreather mask to deliver low-flow oxygen. Non rebreather masks are designed to deliver high concentrations of oxygen (typically 60% to 100%).

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The nurse performing tracheostomy care will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following should the nurse do after noticing a rise in the water seal with client inspiration?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about a nonrebreather mask. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

The nurse takes into consideration that a pulse oximeter may not give an accurate reading if the patient is:

A patient requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should:

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

A nurse is reinforcing teaching with a newly licensed nurse about the manifestations of hypoxia. Which of the following findings should the nurse include in the teaching?

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?

Older adults are more prone to respiratory problems because aging causes which change?

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.)

The nurse performing tracheostomy care will: