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
A) Correct - Flaring of the nares is a sign of increased respiratory effort and can indicate acute respiratory distress.
B) Incorrect - While a resting respiratory rate of 35 breaths/min is elevated for a 4-month-old infant, it may not necessarily indicate acute distress, especially when considered along with other signs.
C) Incorrect - Bilateral bronchial breath sounds may indicate lung pathology, but they are not specific to acute respiratory distress.
D) Incorrect - Diaphragmatic respirations, where the abdomen moves more than the chest during breathing, are normal for infants. They do not necessarily indicate acute respiratory distress.
Correct Answer is D
Explanation
A) Incorrect- While the history of vomiting is important to assess, it may not be the most crucial information to gather at this point, as the client is postoperative and the focus is on immediate postoperative care.
B) Incorrect- While assessing for fluid intake is important, the client's refusal of ice chips is not an urgent concern compared to other potential complications, such as pain management, oxygenation, and fluid balance.
C) Incorrect- These assessments are important, but the client's history of right hemicolectomy and the current infusion and medication administration require closer attention to fluid balance, pain control, and oxygenation.
D) Correct- While all options are important to consider, the most critical information in this scenario is assessing peripheral pulses and the range of motion of both legs. A right hemicolectomy involves abdominal surgery and decreased or absent peripheral pulses along with a limited range of motion could indicate impaired circulation, thrombosis, or other post-operative complications. These findings might necessitate prompt intervention to prevent potential complications.
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