A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

Perform suctioning.

Instill saline into the tubing.

Check the cuff pressure.

Increase the humidification.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A, Perform suctioning. Restlessness and crackles in the lungs may indicate respiratory distress or airway obstruction, which may be due to mucus or secretions blocking the tracheostomy tube. Performing suctioning helps clear the airway of secretions, which will improve the client's breathing. Choice B is incorrect because instilling saline into the tubing is not a common intervention for managing restlessness and crackles. Choice C is incorrect because checking the cuff pressure is not related to managing restlessness and crackles. Choice D is incorrect because increasing humidification is not a common intervention for managing restlessness and crackles.

Other choices:

Instill saline into the tubing: Instilling saline into the tubing is not a common intervention for managing restlessness and crackles.

Check the cuff pressure: Checking the cuff pressure is not related to managing restlessness and crackles.

Increase the humidification: Increasing humidification is not a common intervention for managing restlessness and crackles.

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Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is choice D. The nurse should identify an oral temperature of 39°C (102.2°F) as the priority finding in a client who is postoperative following a total thyroidectomy for hyperthyroidism. An elevated temperature can indicate infection, which is a risk after surgery. The nurse should report this finding to the provider immediately.

Choices A, B, and C are incorrect because moderate amount of serosanguineous drainage on dressings, serum calcium level 9.2 mg/dL, and report of a sore throat, respectively, are expected findings after a total thyroidectomy and do not require immediate action.

A. The client has a history of breast cancer. B. The client takes ibuprofen for headaches. C. The client consumed citrus juice 3 days before the test. D. The client had a hemorrhoidectomy 1 year ago. E. The client had a hemorrhoidectomy 1 year ago.

Correct Answer is B

Explanation

The client takes ibuprofen for headaches. NSAIDs such as ibuprofen can cause gastrointestinal bleeding, which can result in a false positive result on a fecal occult blood test.

Option A is incorrect because breast cancer is not associated with false-positive fecal occult blood results.

Option C is incorrect because citrus juice does not affect the fecal occult blood test.

Option D is incorrect because a hemorrhoidectomy is not associated with false-positive fecal occult blood results.

Reasons why the other options are not answered:

Option A: Breast cancer is not associated with false-positive fecal occult blood results.

Option C: Citrus juice does not affect the fecal occult blood test.

Option D: A hemorrhoidectomy is not associated with false-positive fecal occult blood results.

View Question and Answer

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A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a total thyroidectomy for hyperthyroidism. Which of the following findings should the nurse identify as the priority?

Correct Answer is D

Explanation

A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

Correct Answer is B

Explanation

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A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

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