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A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Check for secretion clearance.

Check the function of the suction catheter.

Don sterile gloves.

Adjust the suction to 120 to 150 mm Hg.

Insert the catheter without suction.

Apply intermittent suction while rotating the catheter

Hyperoxygenate the client.

Answer and Explanation

The Correct Answer is B,C,D,G,E,F,A

Check the function of the suction catheter: Ensures the catheter is functioning properly before starting the procedure.

Don sterile gloves: Maintains asepsis during the suctioning procedure.

Adjust the suction to 120 to 150 mm Hg: Proper suction pressure prevents mucosal trauma.

Hyperoxygenate the client: Prevents hypoxia during the suctioning process.

Insert the catheter without suction: Prevents trauma to mucosa by reducing suction on insertion.

Apply intermittent suction while rotating the catheter: Effectively clears secretions while minimizing tissue damage.

Check for secretion clearance: Ensures the airway is clear and the procedure was effective.

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Correct Answer is A

Explanation

A. Two deep breaths, then inhale deeply again and force out the air quickly: This technique helps clear mucus by mobilizing it toward the larger airways for expulsion.
B. One deep breath and quickly exhale: This method is less effective in mobilizing secretions compared to multiple preparatory breaths.
C. One breath, hold it for 3 seconds, then forcefully exhale three times with mouth open: Holding the breath promotes mucus loosening, and repeated exhalations help clear secretions. While this technique can be correct in some protocols, it is less common for "forceful" cough instructions and may not be the preferred method.
D. Two breaths and force the air out quickly: Lacks the preparatory deep breath necessary for effective secretion clearance.

A. incomplete expirations. B. decreased oxygen saturation C. impaired cilia D. increased elasticity in thorax and respiratory tissues

Correct Answer is ["A"]

Explanation

A. Incomplete expirations: Age-related decreased lung elasticity impairs full expiration, trapping air in the lungs.
B. Decreased oxygen saturation: Age-related changes in lung tissue reduce gas exchange efficiency.
C. Impaired cilia: Decreased ciliary function reduces the ability to clear mucus and pathogens from the airway.
D. Increased elasticity in thorax and respiratory tissues: Elasticity decreases with aging, reducing lung compliance.

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A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse instructing the patient to perform forceful exhalation coughing would instruct the patient to take in:

Correct Answer is A

Explanation

The nurse is aware that changes occur in the respiratory system after the age of 70 that put the older adult more at risk for respiratory problems. These changes include: (Select all that apply.)

Correct Answer is ["A"]

Explanation

A nurse performing oral suctioning on an adult patient should set the wall suction machine so that the suction pressure is between:

Your patient is breathing shallowly and seems irritable and restless. A nursing action that might help is to have him:

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following should the nurse do after noticing a rise in the water seal with client inspiration?

A nurse is caring for a client who is experiencing respiratory distress. Which of the following positions should the nurse assist the client into?

A nurse is nasopharyngeal suctioning an adult patient to remove thick secretions. The nurse will:

A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

The multiple causes for hypoxia include: (Select all that apply.)

A nurse is collecting data from a client who has a respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse expect?