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 ["A","D"]
Explanation
Choice A rationale
In ARDS, impaired carbon dioxide elimination due to shunting can occur. Shunting refers to the diversion of blood from areas of the lung that are ventilated to areas that are not, leading to impaired gas exchange.
Choice B rationale
Decreased pulmonary arterial pressure due to ventilation-perfusion (V/Q) mismatch is not a typical finding in ARDS3.
Choice C rationale
Hypoxemia due to dead space is not a typical finding in ARDS. Dead space refers to areas of the lung that are ventilated but not perfused.
Choice D rationale
Decreased pulmonary compliance due to stiffness is a typical finding in ARDS. The lungs become stiff and less compliant due to the accumulation of fluid and inflammatory cells in the alveoli and interstitial space.
Correct Answer is A
Explanation
Choice A rationale
Amoxicillin-clavulanate is a type of antibiotic that falls under the class of penicillin antibiotics. If a patient is allergic to penicillin, they should not take amoxicillin as it belongs to the penicillin class of antibiotics and must be avoided. Therefore, if a nurse is caring for a child who is allergic to penicillin, they should verify a prescription for amoxicillin-clavulanate with the provider.
Choice B rationale
Gentamicin is an aminoglycoside antibiotic, not a penicillin antibiotic. Therefore, it is generally safe for use in patients with a penicillin allergy.
Choice C rationale
Erythromycin is a macrolide antibiotic, not a penicillin antibiotic. Therefore, it is generally safe for use in patients with a penicillin allergy.
Choice D rationale
Amphotericin B is an antifungal medication, not an antibiotic. Therefore, it is generally safe for use in patients with a penicillin allergy.
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