The nurse is performing tracheostomy care for a client who underwent a laryngectomy for laryngeal cancer. During the procedure, the client begins to cough and is unable to clear the secretions. After the nurse suctions the airway, which finding indicates the intervention was effective?
Absence of coarse crackles.
Increase in respiratory rate.
Increase in breath sounds.
Absence of fine crackles.
The Correct Answer is A
A) Correct - The absence of coarse crackles indicates that the airway has been cleared of secretions effectively, and the lung sounds are clearer.
B) Incorrect - An increase in respiratory rate could indicate distress rather than the effectiveness of the intervention.
C) Incorrect - An increase in breath sounds may not necessarily indicate the effectiveness of the intervention, as the quality of breath sounds matters more than the increase.
D) Incorrect - The absence of fine crackles might not directly indicate the effectiveness of the intervention, as other factors can influence lung sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suffered a myocardial infarction (MI) or heart atack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.
The other options are not correct because:
- The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.
- The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.
- The lab results do not indicate risk factors for transient ischemic atack (TIA), which is a temporary interruption of blood flow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.
Correct Answer is B
Explanation
- A bowel pattern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel pattern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.
- A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patterns. It also includes inspecting and auscultating the abdomen for any abnormalities.
- When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel pattern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may affect the client's bowel function.
Therefore, option B is the correct answer, while options A, C, and D are incorrect.
Option A is incorrect because administering a stool softener without assessing the client's bowel pattern may not be appropriate or effective.
Option C is incorrect because encouraging ambulation may help to stimulate bowel activity, but it is not the first action to take.
Option D is incorrect because recommending dietary changes may be helpful for preventing or treating constipation, but it is not the first action to take.
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