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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Wheezes are continuous, high-pitched musical sounds produced by the narrowing of airways, commonly heard in conditions like asthma. They occur mainly during exhalation and are indicative of airflow obstruction.
B. Stridor is a high-pitched, harsh sound that occurs during inspiration, often associated with an upper airway obstruction, such as laryngospasm or a foreign body.
C. Crackles are fine, crackling sounds heard during inspiration, typically due to fluid accumulation in the lungs (e.g., in pneumonia or heart failure).
D. Rhonchi are low-pitched, snoring sounds caused by the obstruction or narrowing of larger airways, often heard in conditions like chronic bronchitis, but they are not high-pitched like wheezes.
Correct Answer is A
Explanation
A. Tachypnea, or rapid breathing, is a common finding in pneumonia due to hypoxia and the body's attempt to compensate for impaired gas exchange in the lungs. It is one of the hallmark signs of pneumonia.
B. Bradycardia is uncommon in pneumonia. Tachycardia (increased heart rate) is more frequently observed as the body compensates for the infection and reduced oxygenation.
C. Hypothermia is not typically associated with pneumonia; more commonly, fever (hyperthermia) is present as a sign of infection.
D. A pulse deficit is a sign of a heart condition, such as atrial fibrillation, not typically related to pneumonia.
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