A nurse is reinforcing teaching with a newly licensed nurse about tracheostomy care for a toddler. Which of the following instructions should the nurse include in the teaching?

Secure the tracheostomy ties so that fingers cannot fit between the ties and the neck.

Suction for 20 seconds.

Clean secretions from the tube using hydrogen peroxide.

Set the vacuum pressure at 120 mmHg for suctioning.

Answer and Explanation

The Correct Answer is D

A) Secure the tracheostomy ties so that fingers cannot fit between the ties and the neck. The ties should be secure but loose enough to fit one finger between the ties and the neck to prevent skin breakdown and maintain comfort.
B) Suction for 20 seconds. Suctioning for 20 seconds is too long and may cause hypoxia. Suction should not exceed 5 to 10 seconds.
C) Clean secretions from the tube using hydrogen peroxide. Hydrogen peroxide can irritate the delicate tissues and is not recommended. Saline or prescribed cleaning agents are preferred.
D) Set the vacuum pressure at 120 mmHg for suctioning. For a toddler, suction pressure should typically be between 80 and 120 mmHg to prevent mucosal damage.

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Correct Answer is C

Explanation

A. Take a good nap: While rest is important, shallow breathing and irritability may indicate inadequate ventilation, which won't improve solely with sleep.
B. Turn, cough, and deep breathe: This helps open the airways, promotes alveolar expansion, and clears secretions, which may improve oxygenation and reduce restlessness.
C. Submit to a back rub: Although comforting, it does not directly address shallow breathing or improve oxygenation.
D. Take some pain medication: Pain control can be essential, but this action is premature without assessing whether pain is the cause of shallow breathing.

A. The client is grasping his abdomen. B. The client is coughing. C. The client cannot speak. D. The client is hyperventilating.

Correct Answer is C

Explanation

A. The client is grasping his abdomen: Grasping the abdomen may indicate pain or cramping, not necessarily airway obstruction.
B. The client is coughing: Effective coughing suggests that the airway is partially open and the client is moving air, meaning abdominal thrusts are not required.
C. The client cannot speak: Inability to speak or cough is a sign of complete airway obstruction, indicating the need for abdominal thrusts.
D. The client is hyperventilating: Rapid breathing is not a typical sign of choking and does not warrant abdominal thrusts.

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A nurse is reinforcing teaching with a newly licensed nurse about tracheostomy care for a toddler. Which of the following instructions should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

A nurse in a long-term care facility sees a client who is choking. Which of the following data should the nurse identify as requiring an abdominal thrust?

Correct Answer is C

Explanation

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

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

A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands, and cannot talk. Which of the following actions should the nurse take?

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

The nurse loosens mucus plugs by using percussion on a patient over the area of the:

A patient has collapsed and cannot be aroused by asking loudly, "Are you okay?" The next action should be to:

Which is a function of the respiratory system?

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.)