A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?
Thinning of mucous secretions
Decreased peak inspiratory pressure
Presence of a productive cough
Flattening of the artificial airway cuff
The Correct Answer is B
Choice A reason
While thinning of secretions can be a positive sign, it's not always visible. A decrease in peak inspiratory pressure is a more objective indicator of improved airway patency.
Choice B reason.
Peak inspiratory pressure is the maximum pressure required to push air into the lungs. If suctioning is effective, it will remove secretions and reduce airway resistance, leading to a decrease in peak inspiratory pressure.
Choice C reason:
While a productive cough can indicate that secretions are being moved, it doesn't directly measure the effectiveness of suctioning.
Choice D reason:
Flattening of the artificial airway cuff: Flattening of the artificial airway cuff is not a relevant indicator of the effectiveness of suctioning. The cuff of an endotracheal tube is inflated to prevent air leaks around the tube and to maintain proper ventilation. It is not directly related to the effectiveness of suctioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Obesity is not a risk factor for osteoporosis. In fact, obesity may have a protective effect on bone density due to increased mechanical loading and higher levels of estrogen in adipose tissue.
B. Acromegaly is not a risk factor for osteoporosis. Acromegaly is a condition caused by excess growth hormone, which leads to increased bone formation and remodeling.
C. Estrogen replacement therapy is not a risk factor for osteoporosis. Estrogen replacement therapy can help prevent bone loss and reduce the risk of fractures in postmenopausal women with low estrogen levels.
D. Sedentary lifestyle is a risk factor for osteoporosis. Sedentary lifestyle reduces physical activity and muscle strength, which decreases bone stimulation and increases bone resorption.
Correct Answer is C
Explanation
A. Palpate the degree of edema. This is incorrect because palpating the degree of edema requires clinical judgment and skill, which are beyond the scope of practice of an AP.
B. Regulate IV pump fluid rate. This is incorrect because regulating IV pump fluid rate is a nursing responsibility that involves calculating and adjusting the infusion rate based on the client's condition and orders.
C. Measure the client's daily weight. This is correct because measuring the client's daily weight is a routine task that can be delegated to an AP, as long as the nurse provides clear instructions and monitors the results. The client's daily weight is an indicator of fluid balance and can help evaluate the effectiveness of treatment.
D. Assess the client's vital signs. This is incorrect because assessing the client's vital signs requires interpretation and analysis of data, which are nursing functions that cannot be delegated to an AP.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today