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 C
Explanation
A. Skipped eating lunch would more likely cause hypoglycemia rather than diabetic ketoacidosis (DKA). When a person with type 1 diabetes skips a meal but still takes insulin, blood glucose levels drop, leading to hypoglycemia, not the elevated glucose and ketone production seen in DKA.
B. Incorrectly administered too much insulin would also result in hypoglycemia rather than DKA. Administering excessive insulin causes blood glucose levels to fall too low, which does not trigger the fat breakdown and ketone production that characterize DKA.
C. Had a cold and ear infection for the past two days is the most likely cause of diabetic ketoacidosis. Illness and infection cause the body to release stress hormones such as cortisol and adrenaline, which increase blood glucose levels and counteract insulin. In type 1 diabetes, insufficient insulin leads to hyperglycemia, fat breakdown for energy, and the production of ketones, resulting in DKA.
D. Ate an extra peanut butter sandwich before gym class would not cause DKA. Consuming extra food may raise blood glucose temporarily, but it would not lead to the severe insulin deficiency and ketone production seen in DKA, especially if the adolescent took insulin as prescribed.
Correct Answer is A
Explanation
Demonstrate how to administer medication via a feeding tube.The picture shows that the newly hired PN is about to make a serious error by adding the medication directly to the feeding bag, which can cause clogging, contamination, or inaccurate dosing of the medication. The PN should demonstrate how to administer medication via a feeding tube correctly, which involves stopping the feeding, flushing the tube with water, instilling the medication, flushing again, and resuming the feeding.
The other options are not correct because:
- Confirming that the medication is only administered once daily is not relevant or helpful, as it does not address the error or teach the correct technique of administering medication via a feeding tube.Determining if the medication is compatible with the solution is not necessary or appropriate, as the medication should not be mixed with the solution in the first place, but given separately through the feeding tube.
- Offering to assist in calculating the rate of flow for the mixture is not relevant or helpful, as there should be no mixture of medication and solution in the feeding bag, but separate administration of each through the feeding tube.
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