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

Answer and Explanation

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.

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Correct Answer is ["A","C","D","E"]

Explanation

Smoking, Diabetes, Atherosclerosis, and Weak pedal pulses.

Factors that contribute to poor circulation to the limb include:

Smoking: It can cause constriction and damage to the blood vessels, leading to poor circulation.
Diabetes: High blood sugar levels can damage blood vessels and nerves, leading to poor circulation.
Atherosclerosis: This is a condition where plaque builds up in the arteries, narrowing them and reducing blood flow.
Weak pedal pulses: This can be a sign of reduced blood flow to the lower extremities. A sodium-restricted diet (Choice B) is not typically associated with poor circulation.

A. Encourage self-care. B. Assist the patient in identifying coping behaviors. C. Prevent self-directed violence. D. Identify support systems.

Correct Answer is C

Explanation

Choice A rationale

Encouraging self-care is important, but it may not be the immediate priority if the patient is exhibiting manic behavior and has recently experienced significant personal stressors.

Choice B rationale

Assisting the patient in identifying coping behaviors is a key part of treatment, but it may not be the immediate priority if the patient is at risk of self-harm.

Choice C rationale

Preventing self-directed violence is the priority action. Patients exhibiting manic behavior may have impaired judgment and impulse control, putting them at risk of self-harm.

Choice D rationale

Identifying support systems is important, but it may not be the immediate priority if the patient is at risk of self-harm.

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A nurse is performing tracheostomy care for a patient and plans to remove copious secretions. What actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient suspected of having compromised blood flow to a limb. What factors contribute to poor circulation to the limb?

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is admitting a patient exhibiting manic behavior.The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse’s priority action?

Correct Answer is C

Explanation

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