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 B
Explanation
Antihistamines primarily work by blocking the H1 receptors, which are the receptors responsible for mediating the actions of histamine in the body. By blocking these receptors, antihistamines prevent or reduce the effects of histamine, such as itching, sneezing, runny nose, and watery eyes. This is the main mechanism by which antihistamines provide their therapeutic effects. "Antihistamines block release of histamine from mast cells and basophils." This statement is incorrect. Antihistamines do not block the release of histamine; instead, they block the histamine receptors to prevent the effects of histamine.
"H1 antagonists can bind to H1 receptors, H2 receptors, and muscarinic receptors." This statement is incorrect. H1 antagonists, or H1 receptor blockers, specifically bind to H1 receptors and do not have significant affinity for H2 receptors or muscarinic receptors. "First-generation antihistamines are more selective than second-generation antihistamines." This statement is incorrect. First-generation antihistamines are generally less selective and can have more sedating and anticholinergic effects compared to second-generation antihistamines, which are designed to be more selective for H1 receptors and have reduced sedative properties.
Correct Answer is A
Explanation
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