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 B
Explanation
This finding could indicate the presence of bile leakage, which can occur following a cholecystectomy. The provider should be notified immediately as the client may require further interventions. Incisional pain, shoulder pain, and a dry and intact abdominal dressing are expected findings in the postoperative period.
Choice C, incisional pain 5 out of 10 on a pain scale, is not the correct answer because this level of pain is within the expected range for the postoperative period.
Choice D, abdominal dressing dry and intact, is not the correct answer because this is an expected finding in the postoperative period.
Correct Answer is D
Explanation
The nurse should recommend the pneumococcal vaccine to the client, as this is recommended for all adults over the age of 65 to prevent pneumococcal disease. Choice A is incorrect because the tuberculosis vaccine is not routinely given to adults in the United States. Choice B is incorrect because the HPV vaccine is recommended primarily for young adults to prevent HPV-related cancers. Choice C is incorrect because the MMR vaccine is recommended for children, and most adults have already received it. Choice A is not correct because the tuberculosis vaccine is not routinely given to adults in the United States.
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