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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Albuterol is a short-acting beta-agonist bronchodilator that provides rapid relief of bronchospasm and helps to alleviate the symptoms of respiratory distress in asthma. It acts quickly to relax the smooth muscles in the airways, improving airflow and relieving wheezing, coughing, and shortness of breath. In an acute asthma exacerbation, albuterol is often the first-line medication used to provide immediate relief and improve respiratory function. Prednisone is an oral corticosteroid that has anti-inflammatory effects and is commonly used in the treatment of asthma. However, it is typically administered orally and takes time to exert its effects. In the emergency department setting, the focus is on providing immediate relief of symptoms, and oral medications like prednisone may not have an immediate effect. Ipratropium is an anticholinergic bronchodilator that can be administered via inhalation. While it is effective in relieving bronchospasm, it is generally used as an adjunct to albuterol and not typically the first-line medication for severe respiratory distress in asthma. Fluticasone is an inhaled corticosteroid that has anti-inflammatory effects and is used for long-term management and control of asthma. It is not appropriate for immediate relief of severe respiratory distress and is not typically used as a first-line medication in the emergency department.
Correct Answer is E
Explanation
Dependent edema refers to the accumulation of fluid in the dependent parts of the body, which are areas that are most affected by gravity when a person is in a supine or sitting position for an extended period. The sacrum, which is the triangular bone at the base of the spine, is one such dependent area. It is prone to developing edema when there is increased fluid retention in the body, as seen in the patient's weight gain.
To assess for dependent edema accurately, the nurse can gently press the skin over the sacral area with their fingers and observe the skin turgor or the return of the skin to its normal position after releasing the pressure. If there is edema, the skin may have reduced elasticity and take longer to return to its normal position (poor skin turgor).
While edema can occur in other dependent areas such as the feet, ankles, and lower legs, assessing skin turgor in these areas may not provide an accurate determination of dependent edema as they are located further away from the sacrum and may be influenced by other factors.
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