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

Aminophylline is a bronchodilator that belongs to the xanthine derivative class of medications. It works by relaxing the smooth muscles surrounding the bronchial airways, which leads to bronchodilation. By dilating the airways, aminophylline helps to relieve bronchospasm, improve airflow, and facilitate easier breathing.

Prevent Infection: Aminophylline is not an antimicrobial medication, and its primary action is not related to preventing or treating infections.

Suppress the cough: While aminophylline may have some antitussive (cough-suppressing) effects, its primary action is bronchodilation rather than directly suppressing the cough reflex. Promote Expectoration: Aminophylline is not primarily indicated for promoting expectoration (bringing up mucus). It mainly focuses on bronchodilation to improve airflow and relieve bronchospasm.

A. Suction the client's endotracheal tube B. Add air to the pilot balloon on the endotracheal tube C. Providing ventilation with a bag-valve-mask device D. Place a bit block in the client's mouth

Correct Answer is C

Explanation

A low-pressure ventilator alarm indicates a potential issue with the delivery of adequate air or pressure from the ventilator. The pulse oximetry reading of 85% suggests that the client is not receiving sufficient oxygenation.

Providing ventilation with a bag-valve-mask device allows the nurse to manually assist the client's breathing and ensure proper oxygenation and ventilation while troubleshooting the ventilator alarm. By manually ventilating the client, the nurse can help maintain oxygenation and prevent further hypoxemia until the underlying cause of the alarm can be identified and resolved.

Suctioning the client's endotracheal tube, adding air to the pilot balloon, or placing a bit block in the client's mouth may be appropriate interventions in specific situations, but they are not the immediate priority in this case. The primary concern is to address the low oxygen saturation and ensure adequate ventilation.

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

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Naxlex Comprehensive Predictor Exams

Aminophylline is prescribed for a client with acute bronchitis. A nurse administers the medication, knowing that the primary action of this medication is to:

Correct Answer is A

Explanation

The nurse is caring for a client on a ventilator from complications of pneumonia. The nurse observes the low-pressure ventilator alarm and a pulse oximetry reading of 85%. What should be the nurse's first action?

Correct Answer is C

Explanation

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