A postoperative client with a tracheostomy tube in place suddenly begins have noisy, bubbly sounding respirations. What action should the nurse take first?
Suction the tracheostomy
Change the tracheostomy tube
Notify the healthcare provider
Change the tracheostomy dressing
Do a head to toe assessment
The Correct Answer is A
A. Suctioning the tracheostomy is the priority action to clear secretions, which is likely the cause of the noisy, bubbly respirations. This can help the client breathe more easily.
B. Changing the tracheostomy tube is only necessary if the tube is obstructed or malfunctioning, and suctioning is generally the first step.
C. Notifying the healthcare provider may be needed if suctioning is ineffective or if complications persist, but immediate intervention is required.
D. Changing the tracheostomy dressing does not address the respiratory noise or potential secretion buildup.
E. A head-to-toe assessment may be needed, but the immediate concern is clearing the airway obstruction.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is ["A","C"]
Explanation
A. Pulmonic valve closure is best heard at the base of the heart, near the second intercostal space at the left sternal border.
B. Tricuspid valve sounds are best heard at the lower left sternal border, near the apex rather than the base of the heart.
C. Aortic valve closure is also best heard at the base of the heart, near the second intercostal space on the right sternal border.
D. Mitral valve sounds are heard best at the apex of the heart, near the fifth intercostal space in the midclavicular line, not the base.
Correct Answer is ["A","C","D"]
Explanation
A. A febrile state indicates that the client may not be in an optimal condition to learn effectively, so postponing the session is appropriate.
B. Mild anxiety may not require postponement, as it can be addressed during teaching.
C. Nausea can significantly impair concentration and engagement in learning, warranting a delay.
D. A pain level of 8 out of 10 suggests significant discomfort, making it challenging for the client to focus on learning.
E. Asking questions indicates engagement and a readiness to learn, so this does not warrant postponing the session.