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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. "This test will inform your provider if you are anemic." Serum creatinine is not used to assess anemia. Anemia is often evaluated through tests like hemoglobin and hematocrit.
b. "This test will inform your provider if you have an infection." Serum creatinine is not a direct indicator of infection. It is primarily used to assess kidney function.
c. "This test will inform your provider if you have a thyroid disorder." Serum creatinine is not
used to evaluate thyroid function. Thyroid function is typically assessed through thyroid function tests.
d. "This test will inform your provider how your kidneys are functioning." This is the correct
response. Serum creatinine is a waste product that is filtered by the kidneys, and elevated levels may indicate impaired renal function.
Correct Answer is C
Explanation
a. Droplet precautions: Droplet precautions are used for diseases that are transmitted by
respiratory droplets, such as influenza or pneumonia. HIV is not transmitted through respiratory droplets.
b. Airborne precautions: Airborne precautions are used for diseases that are transmitted through the airborne route, such as tuberculosis. HIV is not transmitted through the airborne route.
c. Standard precautions: Standard precautions are used for the care of all patients, regardless of their diagnosis. These precautions include hand hygiene, use of personal protective equipment (PPE) as needed, and safe injection practices.
d. Contact precautions: Contact precautions are used for diseases that are spread by direct or indirect contact, such as methicillin-resistant Staphylococcus aureus (MRSA). HIV is not
transmitted through contact with intact skin.
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