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.
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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Related Questions
Correct Answer is D
Explanation
A. “I will notify my provider before taking any other medications.” - This statement reflects an understanding of the need to check for potential interactions with other medications, which is an appropriate response.
B. “I have made an appointment to see my dentist next week.” - Dental care is important, and
scheduling an appointment with the dentist is a responsible action. However, it does not indicate a misunderstanding about the medication.
C. “I will take this medication with meals.” - Taking phenytoin with meals is a correct instruction as it can help reduce gastrointestinal side effects.
D. "I'll be glad when my seizures stop so I can quit taking this medicine." - This statement
indicates a misunderstanding about the chronic nature of anti-seizure medications. The client needs further education on the importance of continuing the medication even if seizures stop.
Correct Answer is C
Explanation
a. Magnesium 1.9 mg: This magnesium level is within the expected reference range (1.3-2.1 mEq/L).
b. Chloride 99 mEq/L: This chloride level is within the expected reference range (98-106 mEq/L).
c. Sodium 126 mEq/L: A sodium level of 126 mEq/L is significantly below the normal range (135-145 mEq/L), indicating hyponatremia, which can have serious consequences and requires prompt attention.
d. Potassium 3.6 mEq/L: This potassium level is within the expected reference range (3.5-5.0 mEq/L).
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