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 ["A","B","C"]
Explanation
A. Assess peripheral circulation hourly. This is correct because clients with SCD are at risk of vaso-occlusive crisis, which can impair blood flow to the extremities and cause tissue ischemia and necrosis. The nurse should monitor for signs of poor circulation such as pallor, coolness, numbness, or pain.
B. Assess the client's mouth every 8 hr. This is correct because clients with SCD are prone to oral ulcers, infections, and dental problems due to chronic anemia and reduced oxygen delivery to the oral mucosa. The nurse should inspect the mouth for lesions, bleeding, inflammation, or infection and provide oral hygiene as needed.
C. Use humidification with oxygen therapy. Administer IV fluids. This is correct because clients with SCD need adequate hydration and oxygenation to prevent sickling of red blood cells and further complications. Humidification helps moisten the airways and prevent dehydration of the mucous membranes. IV fluids help maintain fluid and electrolyte balance and reduce blood viscosity.
D. Raise the knee position on the client's bed. This is incorrect because this can impede venous return and worsen peripheral circulation. The nurse should keep the client's extremities in a neutral position and avoid tight or restrictive clothing or devices.
E. Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion. This is incorrect because this can cause mechanical trauma to the arm and trigger a vaso-occlusive crisis. The nurse should use a manual blood pressure cuff and avoid applying pressure to the arm. Platelet transfusion is not indicated for clients with SCD unless they have thrombocytopenia or bleeding.
Correct Answer is ["2"]
Explanation
To calculate how many tablets of levothyroxine the nurse should administer, we'll need to convert the dose to the same unit as the available tablets. Here's the step-by-step process:
Convert the desired dose to milligrams (mg): 50 micrograms (mcg) = 50 / 1000 mg (since 1 mg = 1000 mcg) 50 mcg = 0.05 mg
Now, find out how many tablets of 0.025 mg each are required to achieve the desired dose: Number of tablets = Desired dose (in mg) / Tablet strength (in mg) Number of tablets = 0.05 mg / 0.025 mg Number of tablets = 2 tablets
Therefore, the nurse should administer 2 tablets per dose.
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