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. Overusing a muscle while jogging: Overuse injuries are more commonly associated with strains, not sprains. Strains involve the muscles or tendons.

b. Twisting a ligament while walking: This is an example of a mechanism that can lead to a sprain. A sprain involves the stretching or tearing of ligaments, which connect bone to bone.

c. Impact injury on a joint from a fall: This is more likely to result in a sprain, as it can cause damage to ligaments.

d. Crush injury to a bone from blunt trauma: This type of injury is more likely to affect bones rather than ligaments or tendons, and it would not be considered a sprain or strain.

A. Droplet precautions B. Airborne precautions C. Standard precautions D. Contact precautions

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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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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