A nurse is performing tracheostomy care for a patient and plans to remove copious secretions. What actions should the nurse take?
Lubricate the suction catheter tip with sterile saline
Hyperventilate the patient on 100% oxygen prior to suctioning
Perform chest physiotherapy prior to suctioning
Suction two to three times with a 60-second pause between passes
The Correct Answer is D
Choice A rationale
Lubricating the suction catheter tip with sterile saline is not recommended because it can introduce bacteria into the tracheostomy tube and cause infection.
Choice B rationale
Hyperventilating the patient on 100% oxygen prior to suctioning is not necessary and can cause complications such as oxygen toxicity.
Choice C rationale
Performing chest physiotherapy prior to suctioning is not typically done during tracheostomy care. Chest physiotherapy is a separate procedure that involves physical techniques to remove mucus from the respiratory tract.
Choice D rationale
Suctioning two to three times with a 60-second pause between passes is the correct action. This helps to remove secretions effectively without causing hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Phenytoin is an antiepileptic medication used to control seizures. It’s important for the patient to understand that they should not switch brands of this medication without consulting their healthcare provider. Different brands of phenytoin can have different effects, and switching could potentially lead to changes in seizure control.
Choice B rationale
Regular dental appointments are important for patients taking phenytoin. This medication can cause gum overgrowth (gingival hyperplasia), so good oral hygiene and regular dental check- ups are essential.
Choice C rationale
It’s crucial for patients to notify their doctor before taking any other medications. Phenytoin can interact with many other drugs, altering their effectiveness or increasing side effects.
Therefore, the patient’s statement indicates an understanding of the need for caution when considering additional medications.
Choice D rationale
Phenytoin is a long-term medication for controlling seizures. It’s not something that patients can stop taking once they feel better. Abruptly stopping the medication can lead to withdrawal
seizures. Therefore, the patient’s statement, “I’ll be glad when I can stop taking this medicine,” indicates a need for further teaching about the importance of continuing the medication as prescribed.
Correct Answer is C
Explanation
Choice A rationale
Bumetanide is a diuretic, which means it helps your body get rid of extra water. This can make you urinate more often. Taking the second dose at night could disrupt your sleep.
Choice B rationale
While it’s important to monitor fluid intake when taking a diuretic, there’s no specific requirement to limit fluid intake to 1.5 liters a day. Fluid needs can vary based on individual circumstances.
Choice C rationale
Bumetanide can sometimes cause hearing changes or loss, which is usually reversible once the medication is stopped. Therefore, patients should report any changes in hearing to their healthcare provider.
Choice D rationale
Bumetanide can cause the body to lose potassium, which is an important nutrient for heart function. Therefore, it’s usually recommended to consume foods high in potassium, not avoid them.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.