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 A

Explanation

a. Increasing dyspnea: Atelectasis is the collapse of alveoli, leading to decreased lung volume and impaired gas exchange. Dyspnea (difficulty breathing) is a common symptom as the lung's ability to oxygenate the blood is compromised.

b. Dry cough: A dry cough may be present, but it is not specific to atelectasis. It can occur for various reasons postoperatively.

c. Facial flushing: Facial flushing is not a typical finding in atelectasis. It is more commonly associated with conditions such as fever or allergic reactions.

d. Decreasing respiratory rate: Atelectasis can lead to increased respiratory rate as the body tries to compensate for decreased lung function. A decreasing respiratory rate would be less likely in the presence of atelectasis.

A. A sensory warning that a seizure is imminent B. A brief loss of consciousness accompanied by staring C. A continuous seizure state in which seizures occur in rapid succession D. A period of sleepiness following the seizure during which arousal is difficult

Correct Answer is A

Explanation

a. A sensory warning that a seizure is imminent: An aura is a subjective sensation or warning that a seizure is about to occur. It can manifest as visual, auditory, or other sensory experiences.

b. A brief loss of consciousness accompanied by staring: This describes an absence seizure, not an aura. Absence seizures are characterized by a brief loss of consciousness without convulsions.

c. A continuous seizure state in which seizures occur in rapid succession: This describes status epilepticus, not an aura. Status epilepticus is a medical emergency characterized by prolonged or rapidly recurring seizures.

d. A period of sleepiness following the seizure during which arousal is difficult: This describes the postictal state, not an aura. The postictal state is a period of altered consciousness or

sleepiness that may follow a seizure.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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