A nurse is reinforcing discharge teaching with the partner of a client who requires tracheal suctioning. Which of the following statements by the partner indicates an understanding of the teaching?

"I will wrap the suction catheters in a clean towel to be used again at a later time."

"I will set the suction pressure dial between 80 and 120."

"I will suction for less than 15 seconds while inserting the suction catheter."

"I will suction the mouth before inserting the suction catheter into the tracheostomy."

Answer and Explanation

The Correct Answer is B

Choice A Reason:

The statement “I will wrap the suction catheters in a clean towel to be used again at a later time” is incorrect. Suction catheters should be disposed of after each use to prevent infection. Reusing catheters, even if wrapped in a clean towel, can introduce bacteria into the tracheostomy site, leading to potential infections.

Choice B Reason:

The statement “I will set the suction pressure dial between 80 and 120” is correct. The recommended suction pressure for adults is typically between 80 and 120 mmHg. This range is sufficient to effectively clear secretions without causing trauma to the tracheal mucosa. Setting the suction pressure within this range ensures safe and effective suctioning.

Choice C Reason:

The statement “I will suction for less than 15 seconds while inserting the suction catheter” is incorrect. Suctioning should be performed intermittently and for no longer than 10-15 seconds at a time. However, suctioning should not occur while inserting the catheter. Suction should be applied only while withdrawing the catheter to minimize trauma to the tracheal mucosa.

Choice D Reason:

The statement “I will suction the mouth before inserting the suction catheter into the tracheostomy” is incorrect. Suctioning the mouth before the tracheostomy can introduce oral bacteria into the tracheostomy site, increasing the risk of infection. The correct procedure is to suction the tracheostomy first and then the mouth if needed.

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Correct Answer is A

Explanation

Choice A reason: BUN or blood urea nitrogen 30 mg/dL is above the normal range of 10 to 20 mg/dL and indicates renal impairment or dehydration, which can be caused by contrast dye used during coronary angiography or blood loss during or after the procedure. The nurse should report this value to the provider and monitor the client for signs of acute kidney injury, such as oliguria, edema, or electrolyte imbalances.

Choice B reason: Sinus rhythm 95/min on a cardiac monitor is within the normal range of 60 to 100/min and does not indicate any cardiac arrhythmia or ischemia.

Choice C reason: Respiratory rate 12/min is within the normal range of 12 to 20/min and does not indicate any respiratory distress or hypoxia.

Choice D reason: PTT or partial thromboplastin time 25 seconds is within the normal range of 25 to 35 seconds and does not indicate any bleeding disorder or anticoagulant therapy.

A. Hypothermia B. Referred pain in the right shoulder C. Confusion D. Orange-colored urine

Correct Answer is C

Explanation

Choice c: Confusion is a finding that the nurse should anticipate in an older adult client who has cystitis, which is inflammation of the bladder caused by a bacterial infection. Confusion can be a sign of sepsis or delirium, which are common complications of urinary tract infections in older adults.

Choice a is not correct because hypothermia is not a finding that the nurse should anticipate in an older adult client who has cystitis. Hypothermia can occur in older adults due to impaired thermoregulation, but it is not related to cystitis.

Choice b is not correct because referred pain in the right shoulder is not a finding that the nurse should anticipate in an older adult client who has cystitis. Referred pain in the right shoulder can indicate gallbladder disease, but it is not related to cystitis.

Choice d is not correct because orange-colored urine is not a finding that the nurse should anticipate in an older adult client who has cystitis. Orange-colored urine can be caused by certain medications, foods, or dehydration, but it is not related to cystitis.

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A nurse is reinforcing discharge teaching with the partner of a client who requires tracheal suctioning. Which of the following statements by the partner indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client following a coronary angiography. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the nurse anticipate?

Correct Answer is C

Explanation

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