Which condition or changes indicate to the nurse that a patient with a tracheostomy requires suctioning? Select all that apply.

The client has a fever.

The patient requested that suctioning be performed.

Crackles and wheezing is heard upon auscultation

The tracheostomy dressing has a moderate amount of serosanguineous drainage.

Suction was performed more than (4) hours ago.

Answer and Explanation

Correct Answer : C,D,E

Crackles and wheezing indicate the presence of excessive mucus or secretions in the airways, which may require suctioning to clear the airway and improve breathing.

The presence of serosanguineous drainage on the tracheostomy dressing may indicate increased mucus production or bleeding, suggesting the need for suctioning to remove secretions or assess for any bleeding complications.

Regular suctioning is necessary to maintain a patent airway for patients with a tracheostomy. If suctioning was performed more than 4 hours ago, it may be time for another suctioning session to prevent the accumulation of secretions and maintain airway clearance. While a fever may indicate an underlying infection or inflammation, it does not specifically indicate the need for suctioning. The decision to suction should be based on the patient's respiratory assessment and the presence of respiratory symptoms.

While patient requests and preferences are important, the need for suctioning should be determined based on clinical indicators and assessment findings rather than solely relying on patient requests.

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Correct Answer is A

Explanation

Kawasaki disease is an inflammatory condition that primarily affects children, causing symptoms such as fever, rash, conjunctivitis, swollen lymph nodes, and changes in the hands and feet, including skin peeling. It is important to create a calm and quiet environment for the child to minimize stimulation and discomfort.

Placing the child in a quiet environment helps reduce irritability and allows the child to rest. It also helps prevent further stress and agitation, which can exacerbate the symptoms of

Kawasaki disease. Providing a quiet space can promote comfort and improve the child's overall well-being.

Applying lotion to the hands and feet may be beneficial for soothing any dry or peeling skin, but it is not the priority intervention. Creating a quiet environment to address the child's irritability and discomfort takes precedence.

Encouraging the parents to rest when possible and making a list of foods that the child likes are important aspects of care, but they are not the immediate interventions to address the child's current symptoms of irritability, refusal to eat, and skin peeling. These interventions can be addressed after providing a quiet environment and ensuring the child's comfort.

A. Green B. Yellow C. Red D. Black

Correct Answer is D

Explanation

During triage in a disaster situation, a color tagging system is often used to prioritize and categorize the injured based on the severity of their injuries and the urgency of medical attention required. The colors commonly used in triage are:

● Green tag: Minor injuries that are non-urgent and can typically wait for medical treatment.

● Yellow tag: Injuries that are significant but not immediately life-threatening, requiring medical attention within a few hours.

● Red tag: Critical injuries that are life-threatening but still salvageable with prompt medical intervention.

● Black tag: Injuries that are severe and unsurvivable or incompatible with life. This tag is assigned to individuals who are deceased or have injuries that are beyond the resources available for treatment.

In the given scenario, the absence of breathing, absent radial pulse, prolonged capillary refill, and unresponsiveness indicate a critical condition with no signs of life. Therefore, a black tag would be assigned to this individual.

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Which condition or changes indicate to the nurse that a patient with a tracheostomy requires suctioning? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

Correct Answer is A

Explanation

While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned?

Correct Answer is D

Explanation

Match using the choices provided:

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