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.
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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 C
Explanation
A. CVA tenderness is associated with renal issues, not directly with congestive heart failure.
B. A CVA angle of 160 degrees is abnormal; a normal angle is closer to 90 degrees, indicating potential issues.
C. A greater CVA angle can be observed in patients with kyphosis, where the spine curves excessively, affecting rib positioning.
D. A pneumothorax typically results in reduced breath sounds and tracheal deviation, not specifically linked to CVA angle changes.
E. A barrel chest results in an increased AP diameter, not typically associated with CVA angle changes.