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. This is incorrect because weight gain is not expected in clients who have COPD, as they often have difficulty eating and digesting food due to dyspnea and fatigue.
B. This is incorrect because a decrease in anteroposterior diameter of the chest is not typical of COPD, as the condition causes hyperinflation and air trapping in the lungs, leading to an increase in chest size and a barrel-shaped appearance.
C. This is incorrect because HCO3 24 mEq/L is within the normal range for blood bicarbonate levels, which are 22 to 26 mEq/L. Clients who have COPD often have chronic respiratory acidosis, which stimulates the kidneys to retain bicarbonate and increase its levels in the blood to compensate for the low pH.
D. This is correct because pH 7.31 indicates acidosis, which is common in clients who have COPD due to impaired gas exchange and accumulation of carbon dioxide in the blood.
Correct Answer is D
Explanation
A: Incorrect. Hospital-based hospice care is not a service provided by PACE, which is a program that offers comprehensive medical and social services to eligible older adults who wish to remain in their own homes and communities.
B: Incorrect. Transfer to a skilled care facility is not a goal of PACE, which aims to prevent or delay institutionalization by providing coordinated care and support to older adults with chronic conditions and functional limitations.
C: Incorrect. Telehealth for pacemaker diagnostics is not a specific service offered by PACE, which provides primary care, specialty care, prescription drugs, home health care, personal care, transportation, and other services as needed.
D: Correct. Adult day care services are part of the PACE program, which helps older adults maintain their independence and quality of life by providing socialization, supervision, and assistance with activities of daily living.
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