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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A bladder infection can lead to confusion or other changes in mental status, especially in older adults. A normal temperature and WBC count do not necessarily indicate a bladder infection. Diminished reflexes are not typically associated with a bladder infection.
A: A temperature of 37.3° C (99.1° F) is within the normal range and does not necessarily indicate a bladder infection.
B: A WBC count of 9,000/mm3 is within the normal range and does not necessarily indicate a bladder infection.
D: Diminished reflexes are not typically associated with a bladder infection.
Correct Answer is ["A","D"]
Explanation
The correct answer is a. Dysuria and d. Hematuria.
Choice A rationale:
Dysuria, or painful urination, is a common symptom of cystitis due to the inflammation of the bladder lining.
Choice B rationale:
Bradycardia, or slow heart rate, is not typically associated with cystitis. Cystitis primarily affects the urinary system and does not usually impact heart rate.
Choice C rationale:
Pruritus, or itching, is not a common symptom of cystitis. Itching is more often associated with skin conditions or allergic reactions.
Choice D rationale:
Hematuria, or blood in the urine, can occur with cystitis due to the irritation and inflammation of the bladder lining.
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