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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D","E","F"]

Explanation

1. Alcohol: Alcohol can relax the LES, leading to increased reflux symptoms. 2. Chocolate: Chocolate contains compounds that can relax the LES and contribute to reflux symptoms.

3. Peppermint: Peppermint, including peppermint oil and peppermint-flavored foods, can relax the LES and worsen reflux symptoms.

4. Citrus fruits: Citrus fruits and juices, such as oranges, grapefruits, and lemons, are acidic and can irritate the esophagus, exacerbating GERD symptoms.

5. Cola sodas: Cola sodas, including both regular and diet varieties, can contribute to reflux symptoms due to their carbonation and acidic content.

6. Fatty foods: High-fat foods, such as fried foods, fatty meats, and full-fat dairy products, can delay stomach emptying and increase pressure on the LES, leading to reflux.

A. 5% dextrose in Lactated ringers B. 0.45% sodium chloride C. 0.9 Sodium chloride D. 3% Normal Saline

Correct Answer is C

Explanation

0.9% Sodium chloride is a balanced isotonic solution that closely resembles the electrolyte composition of the extracellular fluid. It is commonly used to treat dehydration because it helps restore fluid volume and electrolyte balance in the body.

5% dextrose in Lactated Ringers: This solution is typically used for fluid and electrolyte replacement in patients who have significant fluid losses or imbalances, but it may not be the best choice for dehydration alone.

0.45% sodium chloride: This solution, also known as half-normal saline, has a lower concentration of sodium chloride and is often used for patients who require hypotonic fluids. It may not provide enough electrolyte replacement for a dehydrated patient. 3% Normal Saline: This solution has a higher concentration of sodium chloride and is typically used for specific indications, such as severe hyponatremia or in critical care settings. It is not the first-line choice for treating dehydration.

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Which condition or changes indicate to the nurse that a patient with a tracheostomy requires suctioning? Select all that apply.

Nursing Test Bank

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The nurse is planning to teach the patient with gastroesophageal reflux disease (GERD) about foods or beverages that decrease lower esophageal sphincter (LES) pressure. What should be included in this list (select all that apply)?

Correct Answer is ["A","B","C","D","E","F"]

Explanation

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Correct Answer is C

Explanation

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