A postoperative client with a tracheostomy tube in place suddenly begins have noisy, bubbly sounding respirations. What action should the nurse take first?

Suction the tracheostomy

Change the tracheostomy tube

Notify the healthcare provider

Change the tracheostomy dressing

Do a head to toe assessment

Answer and Explanation

The Correct Answer is A

A. Suctioning the tracheostomy is the priority action to clear secretions, which is likely the cause of the noisy, bubbly respirations. This can help the client breathe more easily.
B. Changing the tracheostomy tube is only necessary if the tube is obstructed or malfunctioning, and suctioning is generally the first step.
C. Notifying the healthcare provider may be needed if suctioning is ineffective or if complications persist, but immediate intervention is required.
D. Changing the tracheostomy dressing does not address the respiratory noise or potential secretion buildup.
E. A head-to-toe assessment may be needed, but the immediate concern is clearing the airway obstruction.

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Correct Answer is B

Explanation

A. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.
B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.
C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.
D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.
E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.

A. Administer oxygen as ordered B. Allow client to choose when to eat meals C. Do not allow family to visit D. Ensure client gets at least 8 hours of sleep E. Place client farther from the nurse's station

Correct Answer is A

Explanation

A. Administering oxygen is crucial for clients with pneumonia, as it helps ensure adequate oxygenation, especially if respiratory function is compromised.
B. Allowing the client to choose when to eat does not directly impact the treatment of pneumonia.
C. Restricting family visits is generally not necessary unless infection control policies require it.
D. While rest is important, it is not as critical as maintaining oxygenation.
E. The location of the client in relation to the nurse’s station does not directly affect pneumonia treatment.

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A postoperative client with a tracheostomy tube in place suddenly begins have noisy, bubbly sounding respirations. What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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