A nurse is caring for a client who is postoperative following a tracheostomy and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

Provide humidified oxygen.

Prelubricate the suction catheter tip with sterile saline when suctioning the airway.

Perform chest physiotherapy prior to suctioning.

Hyperventilate the client with 100% oxygen before suctioning the airway.

Answer and Explanation

The Correct Answer is A

a. Provide humidified oxygen: Humidification helps prevent the drying of mucous membranes, making secretions more manageable and less tenacious. This is an acceptable method to thin

secretions in a client with a tracheostomy.

b. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: While lubrication with sterile saline is a common practice during suctioning to reduce trauma to the airway, it does not directly address the tenacity of secretions.

c. Perform chest physiotherapy prior to suctioning: Chest physiotherapy is a technique used to mobilize respiratory secretions, but it may not directly address the tenacity of secretions.

d. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation with 100% oxygen is not a routine practice and may lead to respiratory alkalosis. Providing

humidified oxygen is a more appropriate approach.

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Correct Answer is B

Explanation

a. Urine in the drainage appliance: The presence of urine in the drainage appliance is expected in a client with an ileal conduit, as this is the route for urine to exit the body.

b. Feces in the drainage appliance: An ileal conduit is created for urinary diversion, and feces

should not be present in the drainage appliance. This finding could indicate a complication and should be reported.

c. Mild edema of the stoma: Mild edema of the stoma may be expected in the early postoperative period and may not require immediate reporting unless it worsens.

d. Redness of the stoma: Some redness is normal around a stoma, and it may not require immediate reporting unless there are signs of infection or worsening inflammation.

A. Postictal phase B. Presence of absence seizures C. Aura phase D. Presence of automatisms

Correct Answer is A

Explanation

a. Postictal phase: The postictal phase refers to the period following a seizure during which the individual may be drowsy, confused, or sleepy. This phase can last varying amounts of time.

b. Presence of absence seizures: Absence seizures are characterized by brief episodes of staring and altered consciousness but do not typically have a postictal phase with prolonged sleepiness.

c. Aura phase: The aura phase occurs before a seizure and involves sensory or perceptual changes that serve as a warning sign. It does not describe the postictal state.

d. Presence of automatisms: Automatisms are repetitive, non-purposeful movements that can occur during certain types of seizures but do not describe the postictal state of sleepiness.

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A nurse is caring for a client who is postoperative following a tracheostomy and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

Nursing Test Bank

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