Review

The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions would the nurse perform for this procedure? Select all that apply. Answer Options 1. Apply suction for up to 10 seconds. 2. Hyperoxygenate the client before suctioning. 3. Set the wall suction unit pressure at 160 mm Hg. 4. Apply suction while gently inserting the catheter. 5. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met, and then pull the catheter back 1 cm.

1. Apply suction for up to 10 seconds. 2. Hyperoxygenate the client before suctioning. 5. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met, and then pull the catheter back 1 cm

The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter?

10 seconds

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. Which statements indicate prevention of transmission of tuberculosis? Select all that apply. Answer Options 1. "I will bleach my clothes and bedding after use." 2. "My family and I will practice good hand hygiene." 3. "I will discard disposable tissues into a plastic bag." 4. "I will cover my mouth when I cough, sneeze, or laugh." 5. "All the deep pile carpeting will be removed from my home."

2. "My family and I will practice good hand hygiene." 3. "I will discard disposable tissues into a plastic bag." 4. "I will cover my mouth when I cough, sneeze, or laugh."

The nurse is preparing to perform nasotracheal suctioning on a client. The nurse places the client's bed in which position to effectively perform this procedure? Refer to figure.

A

A child is brought to the emergency department for treatment of an acute asthma attack. The nurse prepares to administer which medication first?

A β2-agonist

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?

Aspiration of gastric contents occurs when suctioning.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which would the nurse expect to note in this client? Select all that apply. Answer Options A. Hypocapnia B. Dyspnea during exertion C. Presence of a productive cough D. Difficulty breathing while talking E. Increased oxygen saturation with exercise F. A shortened expiratory phase of respiration

B. Dyspnea during exertion C. Presence of a productive cough D. Difficulty breathing while talking

The nurse is caring for an older client who is on bed rest. The nurse plans which intervention to prevent respiratory complications?

Changing the client's position every 2 hours

The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action would the nurse implement?

Check the amount of suction pressure being applied.

A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention?

Check the client for spontaneous breathing.

Levalbuterol via inhalation is prescribed for a client with a diagnosis of emphysema. The nurse reinforces instructions to the client regarding the medication and teaches the client about the dietary restrictions that must be implemented while taking this medication. The nurse determines that the client understands the dietary instructions when the client states that they will avoid which food choice?

Cocoa

The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made?

Coughing occurs with suctioning.

The nurse is assisting a client with a closed chest tube drainage system to get out of bed to a chair. During the transfer, the chest tube gets caught in the leg of the chair and accidentally dislodges from the insertion site. Which action would the nurse implement?

Cover the insertion site with sterile gauze.

The nurse reinforces client instructions about ethambutol. The nurse determines that the client understands the instructions if the client indicates to report which occurrence?

Difficulty discriminating the color red from green

The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?

Disconnect the suction source from the catheter.

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign or symptom would the nurse expect the client to experience?

Dyspnea

The nurse suspects that a client has a pulmonary embolism when the client exhibits which signs and symptoms?

Dyspnea, tachypnea, and tachycardia

A client with tuberculosis who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse recognizes that the client is experiencing which adverse effect?

Peripheral neuritis

A client has a chest tube that is attached to a chest drainage system. The chest tube becomes disconnected. What would the nurse do immediately?

Put the open end under sterile water.

The nurse is caring for a client who is being treated for a pneumothorax with a closed chest tube drainage system. When repositioning the client, the chest tube disconnects from the drainage system. Which nursing action would be immediate?

Reattach the chest tube to the drainage system.

The low-exhaled volume (low-pressure) alarm sounds on a ventilator. The nurse rushes to the client's room and checks the client but is unable to determine the cause of the alarm. Which would be the next immediate nursing action?

Ventilate the client with a resuscitation bag.