A nurse is caring for a client who has a tracheostomy.
Based on the Nurses Notes and Diagnostic Results, which of the following is a manifestation in the client?
The client appears restless.
The client’s SaO2 is 92% on 40% humidified oxygen via tracheostomy collar.
The client’s lung fields have scattered rhonchi throughout.
The client’s tracheostomy was suctioned for thin clear secretions.
The Correct Answer is A
Choice A rationale
Restlessness in a client with a tracheostomy could indicate respiratory distress or hypoxia. It’s important for the nurse to further assess the client’s vital signs, oxygen saturation, and overall appearance.
Choice B rationale
A SaO2 of 92% on 40% humidified oxygen via tracheostomy collar is within the acceptable range for a client with a tracheostomy. However, it’s important to consider the client’s baseline SaO2 and any changes in their condition.
Choice C rationale
Scattered rhonchi throughout the lung fields could indicate secretions in the airways. However, this finding alone does not necessarily indicate a problem with the tracheostomy.
Choice D rationale
Suctioning of thin clear secretions from a tracheostomy is a routine part of tracheostomy care. This finding does not necessarily indicate a problem with the tracheostomy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Placing a tracheostomy tray at the client’s bedside is not the first action a nurse should take when a client is diagnosed with ARDS. While a tracheostomy may be necessary in some cases, it is not the immediate priority.
Choice B rationale
Administering IV prophylaxis for thromboembolism is important in the management of ARDS, but it is not the first action a nurse should take. The immediate priority is to ensure adequate oxygenation.
Choice C rationale
Preparing to assist with intubation of the client is the first action a nurse should take when a client is diagnosed with ARDS. Intubation and mechanical ventilation are often required to ensure adequate oxygenation in clients with ARDS3.
Choice D rationale
Administering IV prophylaxis for stress ulcers is important in the management of ARDS, but it is not the first action a nurse should take. The immediate priority is to ensure adequate oxygenation.
Correct Answer is B
Explanation
Choice A rationale
A chocolate milkshake may be soothing, but it is not the best choice for a patient with bacterial pharyngitis due to its high sugar content, which can promote bacterial growth.
Choice B rationale
Chicken noodle soup is a good choice as it is soothing, easy to swallow, and provides necessary nutrients.
Choice C rationale
Vanilla ice cream, while soothing, is not the best choice due to its high sugar content.
Choice D rationale
Fruit-flavored popsicles, while soothing, are not the best choice due to their high sugar content.
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