The nurse recognizes that, immediately before a tracheostomy cuff deflation, the patient should:

be monitored for respiratory rate

have the cuff pressure checked

have the pharynx suctioned

be administered extra oxygen

Answer and Explanation

The Correct Answer is C

A. Be monitored for respiratory rate: Important for ongoing assessment but not directly related to the deflation process.
B. Have the cuff pressure checked: Necessary during care but not immediately before deflation.
C. Have the pharynx suctioned: Suctioning clears secretions that could be aspirated when the cuff is deflated.
D. Be administered extra oxygen: Beneficial but not a direct prerequisite for cuff deflation.

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Correct Answer is C

Explanation

A) "Repeat your breathing exercise every 2 hrs." Repeating breathing exercises should be done a couple of times every hour to help prevent postoperative complications such as atelectasis and pneumonia.
B) "Inhale through your mouth." Clients should inhale through their nose to filter, warm, and humidify the air.
C) "Hold your breath for 5 seconds." Holding the breath for 5 seconds allows for better lung expansion and optimal oxygen exchange.
D) "Exhale through your nose." Clients are generally advised to exhale through pursed lips to create positive airway pressure and prevent airway collapse.

A. Loop the client's tubes carefully to prevent kinking. B. Clamp the tube when the client is ambulating. C. Place the client flat to avoid leaks in the tubing. D. Keep the collection device below the client's chest level.

Correct Answer is D

Explanation

A. Loop the client's tubes carefully to prevent kinking: Tubes should not be unnecessarily looped, as this may cause obstruction or tension.
B. Clamp the tube when the client is ambulating: Clamping increases the risk of tension pneumothorax and should be avoided unless prescribed for specific procedures.
C. Place the client flat to avoid leaks in the tubing: This position may compromise lung expansion; semi-Fowler’s or Fowler’s position is preferred.
D. Keep the collection device below the client’s chest level: This position uses gravity to prevent backflow of fluid or air into the pleural space.

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The nurse recognizes that, immediately before a tracheostomy cuff deflation, the patient should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing preoperative teaching for a client about coughing and deep breathing. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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

Correct Answer is D

Explanation

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?

The nurse monitoring patients eating in the dining room of a skilled nursing facility notes that a patient begins choking. As the nurse prepares to deliver the Heimlich maneuver, the fist should be positioned:

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

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:

The nurse would determine that this patient is aware of how to use the incentive spirometer device properly when the patient:

A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?

The nurse clarifies that the condition in which there is a decreased amount of oxygen in the blood is:

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