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 D

Explanation

The client's complaint of hemoptysis (coughing up blood) and a positive Mantoux test (4 cm induration) suggest the possibility of tuberculosis (TB) infection. TB is an airborne infectious disease, and placing the client in airborne isolation is necessary to prevent the spread of the infection to others.

Antibiotics may be used to treat tuberculosis, but the initial step would be to isolate the client and confirm the diagnosis before starting specific treatment.

A CT scan may be ordered to further evaluate the client's condition, but it is not the immediate action required in this case. Isolation and confirmation of the diagnosis take priority. While the client may require oxygen therapy based on their respiratory symptoms, it is not the primary action to take at this stage. Isolation and further evaluation are necessary before initiating specific treatments.

A. Sodium level 144 B. Potassium level 1.5 mEq/L C. Blood pressure 102/78 D. Calcium level 9 mg/L

Correct Answer is B

Explanation

Loop diuretics, such as furosemide, are known to cause potassium loss as they increase urine output. A potassium level of 1.5 mEq/L indicates severe hypokalemia (low potassium levels), which can be potentially dangerous and lead to various complications, including cardiac arrhythmias.

Hence, it is important to hold the dose of the loop diuretic and notify the physician so that appropriate interventions can be taken to address the low potassium level, such as prescribing potassium supplementation or adjusting the dosage of the loop diuretic.

A sodium level of 144 is within the normal range (135-145 mEq/L) and does not require immediate action.

A blood pressure of 102/78, although it may indicate hypotension, does not necessarily require holding the dose of the loop diuretic unless it is accompanied by other significant symptoms or clinical concerns.

A calcium level of 9 mg/dL falls within the normal range (8.5-10.5 mg/dL) and does not necessitate holding the loop diuretic dose.

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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

Correct Answer is D

Explanation

Your patient is ordered a loop diuretic at 1000. Which finding below would require you to hold the dose and notify the physician for further orders?

Correct Answer is B

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