Which condition or changes indicate to the nurse that a patient with a tracheostomy requires suctioning? Select all that apply.
The client has a fever.
The patient requested that suctioning be performed.
Crackles and wheezing is heard upon auscultation
The tracheostomy dressing has a moderate amount of serosanguineous drainage.
Suction was performed more than (4) hours ago.
Correct Answer : C,D,E
Crackles and wheezing indicate the presence of excessive mucus or secretions in the airways, which may require suctioning to clear the airway and improve breathing.
The presence of serosanguineous drainage on the tracheostomy dressing may indicate increased mucus production or bleeding, suggesting the need for suctioning to remove secretions or assess for any bleeding complications.
Regular suctioning is necessary to maintain a patent airway for patients with a tracheostomy. If suctioning was performed more than 4 hours ago, it may be time for another suctioning session to prevent the accumulation of secretions and maintain airway clearance. While a fever may indicate an underlying infection or inflammation, it does not specifically indicate the need for suctioning. The decision to suction should be based on the patient's respiratory assessment and the presence of respiratory symptoms.
While patient requests and preferences are important, the need for suctioning should be determined based on clinical indicators and assessment findings rather than solely relying on patient requests.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Loop diuretics, such as furosemide, are known to cause potassium loss as they increase urine output. A potassium level of 1.5 mEq/L indicates severe hypokalemia (low potassium levels), which can be potentially dangerous and lead to various complications, including cardiac arrhythmias.
Hence, it is important to hold the dose of the loop diuretic and notify the physician so that appropriate interventions can be taken to address the low potassium level, such as prescribing potassium supplementation or adjusting the dosage of the loop diuretic.
A sodium level of 144 is within the normal range (135-145 mEq/L) and does not require immediate action.
A blood pressure of 102/78, although it may indicate hypotension, does not necessarily require holding the dose of the loop diuretic unless it is accompanied by other significant symptoms or clinical concerns.
A calcium level of 9 mg/dL falls within the normal range (8.5-10.5 mg/dL) and does not necessitate holding the loop diuretic dose.
Correct Answer is C
Explanation
Excessive exposure to UV light, such as sunlight or tanning beds, is a known trigger for SLE exacerbations. It is important for individuals with SLE to protect their skin from the sun by wearing protective clothing, using sunscreen, and avoiding direct sunlight during peak hours. Having a family history of SLE increases the risk of developing the disease. While it is not a trigger in itself, it is an important piece of information for the client to be aware of, as it may indicate a genetic predisposition to the condition.
Acetaminophen is a commonly used over-the-counter pain reliever. While it can help manage pain associated with SLE, it is not typically considered a trigger for exacerbations. Menopause, which marks the end of a woman's reproductive years, does not directly trigger SLE exacerbations. However, hormonal changes during menopause can potentially affect disease activity in some individuals. It is important for the client to discuss any changes or concerns with their healthcare provider to manage their symptoms effectively.
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