Which action would the nurse take first for a patient with a tracheostomy who appears anxious and is having difficulty in coughing up thick respiratory secretion?
Encourage the patient to increase oral fluid intake.
Apply humidification to the patient's oxygen.
Suction the tracheostomy.
Offer reassurance.
The Correct Answer is C
A. Encouraging the patient to increase oral fluid intake may help with secretion thinning over time, but in the immediate situation of thick respiratory secretions, it will not provide immediate relief.
B. Applying humidification to the oxygen would be helpful over time to thin secretions, but it is not the immediate action needed to address the difficulty in clearing thick secretions.
C. Suctioning the tracheostomy is the priority action in this situation. When a patient with a tracheostomy has difficulty clearing thick secretions, suctioning is the most effective way to relieve the obstruction and improve airflow, thereby addressing the immediate respiratory distress.
D. Offering reassurance is important, but it does not address the patient’s immediate need to clear the airway. Managing the respiratory distress should take priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. In SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion), the body retains excessive water, leading to dilutional hyponatremia (low sodium levels). Administering hypertonic saline (3% NS) can exacerbate the condition by rapidly increasing sodium levels, which may cause demyelination of neurons (a condition called osmotic demyelination syndrome). Hypertonic saline is typically only used in severe hyponatremia with neurologic symptoms and should be carefully monitored.
B. Seizure precautions are appropriate in SIADH due to the risk of seizures from severe hyponatremia, which can lead to cerebral edema and neurological compromise.
C. Fluid restriction of 1000 mL/day is appropriate in SIADH to manage the dilutional hyponatremia by preventing further fluid retention.
D. A sodium-restricted diet is also recommended in SIADH to avoid further dilution of sodium levels and prevent worsening of hyponatremia.
Correct Answer is C
Explanation
A. Visual deterioration is not typically associated with nasal drainage following a hypophysectomy unless the optic nerves or structures are affected during surgery.
B. Diabetes is not related to the glucose content in the nasal drainage; it's unrelated to this situation.
C. The presence of glucose in the drainage indicates a possible cerebrospinal fluid (CSF) leak, as CSF contains glucose. A CSF leak increases the risk of meningitis due to the direct connection to the central nervous system.
D. Hypoglycemia is not associated with the glucose content of drainage fluid. This is more relevant to blood glucose levels.
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