Which action would the nurse take first for a patient with a tracheostomy who appears anxious and is having difficulty in coughing up thick respiratory secretion?

Encourage the patient to increase oral fluid intake.

Apply humidification to the patient's oxygen.

Suction the tracheostomy.

Offer reassurance.

Answer and Explanation

The Correct Answer is C

A. Encouraging the patient to increase oral fluid intake may help with secretion thinning over time, but in the immediate situation of thick respiratory secretions, it will not provide immediate relief.
B. Applying humidification to the oxygen would be helpful over time to thin secretions, but it is not the immediate action needed to address the difficulty in clearing thick secretions.
C. Suctioning the tracheostomy is the priority action in this situation. When a patient with a tracheostomy has difficulty clearing thick secretions, suctioning is the most effective way to relieve the obstruction and improve airflow, thereby addressing the immediate respiratory distress.
D. Offering reassurance is important, but it does not address the patient’s immediate need to clear the airway. Managing the respiratory distress should take priority.

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Correct Answer is B

Explanation

A. Using a lift sheet is helpful for preventing injury and ensuring safe handling of the patient, but it is not the most critical safety measure for a patient with Cushing’s syndrome.
B. Assisting the patient to change positions slowly is the most important safety measure for a patient with Cushing’s syndrome. Patients with Cushing’s syndrome often have osteoporosis and a risk of fractures due to prolonged exposure to high cortisol levels, which can lead to weakened bones. Orthostatic hypotension may also occur, so changing positions slowly can prevent falls.
C. Padding the siderails of the bed is typically done for patients at risk of seizures or those with neurological issues, not as a primary concern for patients with Cushing’s syndrome.
D. While keeping suction equipment at the bedside is important for patients at risk of aspiration or respiratory issues, it is not the most critical measure for a patient with Cushing’s syndrome. The most significant concern is the risk of falls and fractures due to bone weakening and potential hypotension.

A. Blood glucose 80 mg/dL B. Serum sodium 146 mEq/L C. Blood urea nitrogen (BUN) 15 mg/dL D. Urine specific gravity 1.015

Correct Answer is D

Explanation

A. Blood glucose levels are not directly affected by desmopressin, as it is used to treat diabetes insipidus, which is related to antidiuretic hormone (ADH) deficiency, not glucose metabolism.
B. A serum sodium level of 146 mEq/L is slightly elevated and may indicate dehydration, which is common in diabetes insipidus if not well controlled. Desmopressin should help lower the sodium level by reducing the excessive urine output.
C. Blood urea nitrogen (BUN) is typically used to assess kidney function and hydration status, but it is not a primary indicator of the effectiveness of desmopressin in treating diabetes insipidus.
D. A urine specific gravity of 1.015 is within the normal range and indicates more concentrated urine, which is a therapeutic effect of desmopressin. The medication helps the kidneys retain water, leading to more concentrated urine, and improving symptoms of diabetes insipidus.

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Which action would the nurse take first for a patient with a tracheostomy who appears anxious and is having difficulty in coughing up thick respiratory secretion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which safety measure is most important for the nurse to institute for a patient who has Cushing Syndrome?

Correct Answer is B

Explanation

A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that which of the following laboratory findings indicate a therapeutic effect of the medication?

Correct Answer is D

Explanation

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