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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. 5% dextrose in Lactated ringers B. 0.45% sodium chloride C. 0.9 Sodium chloride D. 3% Normal Saline

Correct Answer is C

Explanation

0.9% Sodium chloride is a balanced isotonic solution that closely resembles the electrolyte composition of the extracellular fluid. It is commonly used to treat dehydration because it helps restore fluid volume and electrolyte balance in the body.

5% dextrose in Lactated Ringers: This solution is typically used for fluid and electrolyte replacement in patients who have significant fluid losses or imbalances, but it may not be the best choice for dehydration alone.

0.45% sodium chloride: This solution, also known as half-normal saline, has a lower concentration of sodium chloride and is often used for patients who require hypotonic fluids. It may not provide enough electrolyte replacement for a dehydrated patient. 3% Normal Saline: This solution has a higher concentration of sodium chloride and is typically used for specific indications, such as severe hyponatremia or in critical care settings. It is not the first-line choice for treating dehydration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

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

Explanation

Based on the diagnosis of Dehydration, select which IV solution will be ordered to treat waiting this patient.

Correct Answer is C

Explanation

The patient who is confined to bed in the supine position has gained 5 lbs. in the last 48 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema?

Cephalosporins are similar to another group of beta-lactam antibiotics called the?

What discharge teaching will the nurse provide to a patient who has gastric bypass surgery? Select all that apply.

A patient with a gastric outlet obstruction has been treated with NG decompression. After the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds. What is the best action by the nurse?

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?

While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned?

In reviewing the electrolytes of a patient, the nurse notes the serum potassium level has increased from 4.3 mEq/L to 5.9 mEq/L. Which assessment does the nurse initiate first to prevent further harm?