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 D
Explanation
Answer is: d. Reposition the client.
Explanation: Repositioning the client can help alleviate pain by redistributing pressure and promoting comfort. Since the client's pain level is relatively low (2 on a scale of 0 to 10), this non-pharmacological intervention is an appropriate initial action.
Choice a. is wrong because maintaining the client on bed rest is not an appropriate action for a pain level of 2. Instead, the nurse should encourage the client to mobilize and perform appropriate exercises to prevent complications related to immobility.
Choice b. is wrong because applying a warm, moist compress to the incision area might not be the best action for a client who is 24 hours postoperative, as it could increase the risk of infection and cause discomfort. Cold compresses are often used in the initial postoperative period to reduce swelling and promote comfort.
Choice c. is wrong because administering an additional dose of pain medication is not necessary at this point, as the client's pain level is relatively low. The nurse should consider non-pharmacological interventions first and reassess the client's pain level to determine the need for further pain relief.
Correct Answer is D
Explanation
Ginkgo biloba is a herb that can interact with enoxaparin and increase the risk of bleeding, so the nurse should report its use to the provider. The other options, A (Echinacea), B (Flaxseed powder), and C (Probiotics) do not have any known interactions with enoxaparin, so they do not need to be reported to the provider.
Reasons, why the other choices are not answers, are:
A. Echinacea is a herb that is commonly used to boost the immune system and has not been found to interact with enoxaparin.
B. Flaxseed powder is a dietary supplement that is high in fiber and omega-3 fatty acids and has not been found to interact with enoxaparin.
C. Probiotics are live bacteria that can be found in certain foods or supplements, and they have not been found to interact with enoxaparin.
In summary, the nurse should report the use of Ginkgo biloba to the provider, as it can interact with enoxaparin and increase the risk of bleeding. Echinacea, Flaxseed powder, and Probiotics do not have any known interactions with enoxaparin, so they do not need to be reported to the provider.
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