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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
In a client diagnosed with chronic obstructive pulmonary disease (COPD), an arterial blood gas (ABG) test would typically show an increased level of carbon dioxide (PaCO2)56. This is because COPD affects the ability of the lungs to expel carbon dioxide, leading to its buildup in the blood.
Choice B rationale
An increased pH is not typically seen in COPD. In fact, due to the increased carbon dioxide (which is acidic), the pH may be lower, indicating respiratory acidosis.
Choice C rationale
Decreased alveolar function is a characteristic of COPD, but it is not something that would be directly measured in an ABG test.
Choice D rationale
An increased arterial oxygen (PaO2) is not typically seen in COPD. In fact, due to the impaired gas exchange, PaO2 may be lower.
Correct Answer is C
Explanation
Choice A rationale
PEEP does not decrease trapped oxygen in the alveoli. Instead, it helps to increase the volume of gas remaining in the lungs at the end of expiration, which can improve oxygenation.
Choice B rationale
PEEP does not directly promote independent breathing efforts. It is a mode of mechanical ventilation used to support a patient’s breathing.
Choice C rationale
PEEP keeps the airways and small lung spaces open by increasing the pressure in the lungs at the end of expiration. This can prevent alveolar collapse and improve oxygenation in patients with conditions like ARDS23.
Choice D rationale
While PEEP can be used in the process of weaning a patient off mechanical ventilation, its primary benefit is not facilitating weaning. It is used to improve oxygenation and prevent alveolar collapse.
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