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 D

Explanation

A. Insulin detemir is a long-acting basal insulin used for maintenance therapy, not for the rapid reduction of blood glucose levels in acute conditions like diabetic ketoacidosis (DKA).
B. NPH insulin is an intermediate-acting insulin used for long-term blood glucose control, but it is not appropriate for immediate treatment of DKA.
C. Insulin glargine is also a long-acting insulin that works over a prolonged period, making it unsuitable for emergency situations like DKA.
D. Regular insulin is the preferred choice for treating diabetic ketoacidosis. It is a short-acting insulin that can rapidly reduce blood glucose levels and is used intravenously for immediate intervention in DKA.

A. The client exhales as the medication is released from the inhaler B. The client takes a quick inhalation while releasing the medication from the inhaler C. The client holds his breath for 10 seconds after inhaling the medication D. The client waits 10 min between inhalations

Correct Answer is C

Explanation

A. The client exhales as the medication is released from the inhaler: This is incorrect. The client should inhale deeply while activating the inhaler. Exhaling before inhaling will reduce the effectiveness of the medication.
B. The client takes a quick inhalation while releasing the medication from the inhaler: This is incorrect. The client should inhale slowly and deeply to allow the medication to reach the lungs effectively. A quick inhalation may result in less medication being delivered to the lungs.
C. The client holds his breath for 10 seconds after inhaling the medication: This is the correct action. Holding the breath allows the medication to settle in the lungs, enhancing its therapeutic effect.
D. The client waits 10 min between inhalations: This is not necessary unless instructed by the healthcare provider. Most guidelines suggest waiting 1 to 2 minutes between inhalations of the same medication.

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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?

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