A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

examining the character of the sputum

monitoring the rate of respirations.

auscultating the breath sounds

determining the last time the patient was suctioned

Answer and Explanation

The Correct Answer is C

A. Examining the character of the sputum: While monitoring secretions is important, it does not necessarily indicate the need for immediate suctioning.
B. Monitoring the rate of respirations: An increased respiratory rate can indicate distress but is not a definitive cue for suctioning.
C. Auscultating the breath sounds: This helps identify the presence of secretions or airway obstruction and is a primary indicator for suctioning.
D. Determining the last time the patient was suctioned: Suctioning should be based on clinical need rather than a routine schedule.

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Correct Answer is C

Explanation

A) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. Milking the chest tube is not recommended as it can create excessive negative pressure and damage lung tissue.
B) Notify the provider. This is not the first intervention. The nurse should assess the suction regulator and connections before notifying the provider.
C) Verify that the suction regulator is on. Lack of bubbling often indicates that the suction regulator is off or not functioning correctly. The nurse should first ensure that the regulator is turned on and properly connected.
D) Continue to monitor the client because this is an expected finding. Bubbling should be present in the suction control chamber if suction is applied; therefore, this finding requires immediate assessment.

A. took five quick "huffs" and then coughed vigorously B. exhaled deeply and then inhaled quickly and forcefully three times C. took five deep breaths slowly every 4 hours D. took 10 slow, deep breaths every hour

Correct Answer is D

Explanation

A) Took five quick "huffs" and then coughed vigorously. Huff coughing is a technique used to clear secretions, but it is not the correct method for using an incentive spirometer.
B) Exhaled deeply and then inhaled quickly and forcefully three times. Rapid inhalation and exhalation do not promote effective lung expansion or alveolar recruitment.
C) Took five deep breaths slowly every 4 hours. This frequency is insufficient to prevent atelectasis and postoperative lung complications.
D) Took 10 slow, deep breaths every hour. Taking 10 slow, deep breaths every hour encourages full lung expansion and prevents complications such as atelectasis.

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A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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

Correct Answer is D

Explanation

The nurse clarifies that the cough mechanism is stimulated when:

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