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 C
Explanation
The pH value of 7.5 indicates alkalosis, as it is above the normal range of 7.35-7.45. The elevated bicarbonate (HCO3-) level of 34 mmol/L suggests metabolic alkalosis, as it is higher than the normal range of 22-28 mmol/L. The PaCO2 level of 40 mm Hg falls within the normal range of 35-45 mm Hg.
In this case, the primary disturbance is metabolic alkalosis, which is likely caused by vomiting leading to excessive loss of gastric acid (hydrogen ions) and chloride ions from the stomach. This loss of acid and chloride results in an imbalance of electrolytes and an increase in bicarbonate levels, leading to metabolic alkalosis.
The arterial blood gas results do not indicate any compensation. Compensation occurs when the body attempts to restore the pH balance by adjusting the respiratory or metabolic systems. In this case, there is no compensation observed because the PaCO2 level is within the normal range and not significantly altered.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Aminoglycosides work by binding to the 30S subunit; this binding interferes with the bacterial ribosome's ability to synthesize proteins. By inhibiting protein synthesis, aminoglycosides disrupt bacterial growth and can lead to bacterial cell death.
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