Nokea
During suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal wall and creates a pulling sensation. What is the best action for the nurse to take?
- A. Release the suction by opening the vent
- B. Continue suctioning to remove the obstruction
- C. Increase the pressure
- D. Suction deeper
Correct Answer: A
Rationale: Releasing suction by opening the vent prevents trauma to the tracheal mucosa when the catheter adheres to the wall.
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Select all the correct options that represent the pathophysiology of an asthma attack.
- A. The smooth muscle surrounding the alveoli constricts, limiting oxygenation.
- B. The mucosa lining experiences severe inflammation.
- C. The goblet cells within the mucosa lining produce excessive amounts of mucous.
- D. Too much carbon dioxide is exhaled due to hyperventilation and the patient experiences respiratory alkalosis.
Correct Answer: B,C
Rationale: Asthma involves inflammation of the airway mucosa and excessive mucus production by goblet cells. Smooth muscle constriction occurs in bronchioles, not alveoli, and hyperventilation typically leads to respiratory acidosis due to CO2 retention.
A patient was admitted to the intensive care unit 48 hours ago for treatment of a gunshot wound. The patient has recently developed a productive cough and a fever of 104.3 ' $F$. The patient is breathing on their own and doesn't require mechanical ventilation. On assessment, you note coarse crackles in the right lower lobe. A chest x-ray shows infiltrates with consolidation in the right lower lobe. Based on this specific patient scenario, this is known as what type of pneumonia?
- A. Aspiration pneumonia
- B. Ventilator acquired pneumonia
- C. Hospital-acquired pneumonia
- D. Community-acquired pneumonia
Correct Answer: C
Rationale: Hospital-acquired pneumonia (HAP) develops 48 hours or more after hospital admission, as seen in this patient. Aspiration pneumonia is linked to inhaling foreign material, ventilator-acquired pneumonia requires mechanical ventilation, and community-acquired pneumonia occurs outside healthcare settings.
Which pulse oximetry reading indicates to the nurse that the client has normal tissue oxygenation?
- A. 80 to 90 mm Hg
- B. 95 to 100 mm Hg
- C. 80% to 85%
- D. 95% to 100%
Correct Answer: D
Rationale: A pulse oximetry reading of 95% to 100% indicates normal tissue oxygenation, reflecting adequate oxygen saturation.
Which statement indicates to the nurse the client diagnosed with sleep apnea needs further teaching?
- A. If I lose weight I may not need treatment for sleep apnea.
- B. The CPAP machine holds my airway open with pressure.
- C. The CPAP will help me stay awake during the day while I am at work.
- D. It is all right to have a couple of beers because I have this CPAP machine.
Correct Answer: D
Rationale: Alcohol (D) worsens sleep apnea by relaxing airway muscles, contradicting effective CPAP use. Weight loss (A) can reduce sleep apnea severity. CPAP maintaining airway patency (B) and improving daytime alertness (C) are correct.
The client diagnosed with restrictive airway disease (asthma) has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication?
- A. Do not abruptly stop taking this medication; it must be tapered off.
- B. Immediately rinse the mouth following administration of the drug.
- C. Hold the medication in the mouth for 15 seconds before swallowing.
- D. Take the medication immediately when an attack starts.
Correct Answer: B
Rationale: Rinsing the mouth (B) prevents oral thrush from inhaled glucocorticoids. Tapering (A) applies to systemic steroids, holding/swallowing (C) is incorrect, and attack use (D) is for rescue inhalers.