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 ["A","B","E"]

Explanation

A. An S3 is often associated with a stiff or poorly compliant ventricle.
B. An S3 heart sound can be an indication of congestive heart failure in adults, as it reflects increased fluid volume and pressure in the ventricles.
C. S3 is heard just after S2, not S1.
D. The S3 heart sound is not always pathologic. It is often benign in children, adolescents, and young adults, where it may occur due to a rapid filling phase of the ventricles.
E. In adolescents and younger individuals, an S3 heart sound is usually considered a normal finding.

A. Inquire about personal and family cardiac history B. Ask about fatigue and chest pain C. Inspect for intercostal retractions and nasal flaring D. Palpate the chest for any thrills and heaves E. Auscultate the heart with the diaphragm and bell of stethoscope

Correct Answer is ["A","B"]

Explanation

A. Inquiring about personal and family cardiac history provides essential subjective information on potential hereditary risks and the client’s own cardiac health.
B. Asking about fatigue and chest pain allows the nurse to assess symptoms that may suggest cardiac issues, making it critical subjective data.
C. Inspecting for intercostal retractions and nasal flaring is part of the objective assessment rather than subjective data.
D. Palpating the chest for thrills and heaves is also an objective action, assessing physical findings rather than subjective symptoms.
E. Auscultating the heart with the diaphragm and bell of the stethoscope is an objective assessment to detect sounds rather than gathering subjective information from the client.

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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

When performing a cardiovascular assessment, what would the nurse understand about an S3 heart sound? Select all that apply

Correct Answer is ["A","B","E"]

Explanation

What subjective data should the nurse obtain about a client's cardiac status? Select all that apply.

Correct Answer is ["A","B"]

Explanation

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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?

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