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 C

Explanation

Pancytopenia refers to a decrease in all three major blood cell types: red blood cells (anemia), white blood cells (leukopenia), and platelets (thrombocytopenia). It is a potentially serious side effect that can lead to increased susceptibility to infections, anemia-related symptoms (fatigue, weakness), and an increased risk of bleeding. Prompt reporting is necessary for further

evaluation and appropriate management.

While melena (dark, tarry stools) is a concerning side effect, it typically indicates gastrointestinal bleeding, which should also be reported promptly but may not require immediate action unless the bleeding is severe or accompanied by other symptoms.

Decreased vision can be a side effect of certain medications, including NSAIDs, but it does not usually require immediate reporting unless it is severe or rapidly progressive. Hyperglycemia (high blood sugar) can occur with NSAID therapy, especially in individuals with preexisting diabetes or impaired glucose tolerance. While it should be monitored and managed appropriately, it does not typically require immediate reporting unless it is extremely high or associated with other concerning symptoms.

A. Skin rash B. Hyperglycemia C. Dizziness D. Intense pruritus

Correct Answer is ["A","D"]

Explanation

Signs and symptoms associated with a hypersensitivity reaction to cephalosporin antibiotics can include:

1. Skin rash: Hypersensitivity reactions often manifest as skin rashes, which can range from mild to severe. The rash may be itchy, red, raised, and may spread to different areas of the body.

2. Intense pruritus: Pruritus refers to severe itching, which can be a prominent symptom of a hypersensitivity reaction to cephalosporins.

Dizziness and hyperglycemia are not commonly associated with hypersensitivity reactions to cephalosporins. Dizziness may be a side effect of some medications, including antibiotics, but it is not a specific symptom of a hypersensitivity reaction. Hyperglycemia, or high blood sugar levels, is not typically attributed to a hypersensitivity reaction to cephalosporins. It's important to note that hypersensitivity reactions can vary in severity and may include other symptoms such as fever, swelling, difficulty breathing, wheezing, and anaphylaxis. If a hypersensitivity reaction is suspected, it is crucial to seek immediate medical attention for proper evaluation and management.

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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

A client with systemic lupus erythematosus (SLE) is receiving nonsteroidal anti- inflammatory drug (NSAID) therapy. Which side effect of NSAID therapy should the nurse immediately report to the health care provider?

Correct Answer is C

Explanation

What signs and symptoms are associated with a hypersensitivity reaction that can present with a Cephalosporin?

Correct Answer is ["A","D"]

Explanation

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