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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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.

A. Metabolic acidosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic alkalosis

Correct Answer is B

Explanation

This ABG result indicates that the client has an excess of carbon dioxide (CO2) due to hypoventilation.

A. "Metabolic acidosis" is an incorrect answer because the pH is low and the HCO3 is within normal range.

C. "Respiratory alkalosis" is an incorrect answer because the pH is low and the PaCO2 is elevated.

D. "Metabolic alkalosis" is an incorrect answer because the HCO3 is within normal range, and the pH is low.

Explanation: The ABG result shows a low pH, elevated PaCO2, and normal HCO3, indicating respiratory acidosis. This condition can be caused by conditions that affect breathing, such as pneumonia, asthma, or chronic obstructive pulmonary disease (COPD).

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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 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

A nurse is caring for a client who has pneumonia with dyspnea. The client's ABG results are pH 7.30, PaCO2 50 mm Hg, HCO3 26 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

Correct Answer is B

Explanation

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