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. Have the client refrain from talking for 24 hr: The client only needs to refrain from talking until the anesthesia wears off, usually within an hour. There is no need to refrain from talking for 24 hours.
B. Withhold food and liquids until the client's gag reflex returns: This is the correct action. Following a bronchoscopy, the local anesthetic used can suppress the gag reflex. It is crucial to wait until the gag reflex returns to prevent aspiration when the client eats or drinks. C. Irrigate the client's throat every 4 hr: There is no indication to irrigate the throat routinely. The priority is to ensure that the gag reflex has returned before allowing oral intake.
D. Suction the client's oropharynx frequently: Suctioning is only necessary if the client is unable to clear their secretions or has difficulty breathing. It is not a standard post-procedure intervention.

A. Take the medication with meals. B. Rinse the mouth after administration. C. Check the pulse after medication administration. D. Limit caffeine intake.

Correct Answer is B

Explanation

A. Taking inhaled beclomethasone with meals is not necessary, as this medication works locally in the lungs and does not require food to be absorbed or tolerated.
B. Rinsing the mouth after using inhaled corticosteroids like beclomethasone is important to prevent the development of oral thrush (a fungal infection) and reduce the risk of other side effects, such as hoarseness.
C. Checking the pulse after medication administration is not required for beclomethasone. While some medications affect heart rate, inhaled corticosteroids like beclomethasone are not typically associated with this effect.
D. Limiting caffeine intake is not necessary when using beclomethasone. Caffeine is a stimulant that may interact with some medications, but it does not typically interfere with corticosteroids used in asthma treatment.

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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

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