Nokea
Place in correct sequence the steps from 1-7 used when performing tracheostomy suctioning.
- A. Suction the oral cavity.
- B. Auscultate breath sounds for effectiveness.
- C. Set suction control at 80-120 mm Hg.
- D. Ambu or oxygenate at 100% O2
- E. Apply suction while withdrawing the suction catheter.
- F. Turn the head toward the side to be suctioned.
- G. Auscultate breath sounds prior to suctioning.
Correct Answer: G, C, D, F, E, B, A
Rationale: Sequence: Auscultate breath sounds (G), set suction pressure (C), oxygenate (D), turn head (F), apply suction (E), auscultate post-suction (B), suction oral cavity (A) to clean.
You may also like to solve these questions
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
- A. Inspiration is longer than expiration
- B. Breath sounds are high pitched
- C. Breath sounds are slightly muffled
- D. Inspiration and expiration are equal
Correct Answer: D
Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.
A client is experiencing visual problems at school. She has complained of difficulty seeing the blackboard and squinting. She no longer likes to participate in physical activities such as softball. The client has displayed possible classic symptoms of which refractive error?
- A. Astigmatism
- B. Hyperopia
- C. Myopia
- D. Amblyopia
Correct Answer: C
Rationale: Visual images are blurred and distorted. Symptoms are headaches, burning eyes, fatigue, squinting, and difficulty reading. These symptoms are classic for myopia. Amblyopia is not a refractive error. It is a loss of vision in one or both eyes.
The nurse is caring for a client with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate a need for further teaching?
- A. "I should take the medication immediately before bedtime every night."
- B. "I should remain in an upright position for 30 minutes after taking Fosamax."
- C. "The medication should be taken by mouth with water."
- D. "I should not have any food with this medication."
Correct Answer: A
Rationale: Alendronate should be taken in the morning on an empty stomach, not before bedtime (A), indicating a need for further teaching. Upright positioning (B), taking with water (C), and avoiding food (D) are correct.
A client with a history of chronic kidney disease is admitted with complaints of edema. The nurse should expect the client to have:
- A. Hypernatremia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypokalemia
Correct Answer: C
Rationale: Chronic kidney disease impairs potassium excretion, leading to hyperkalemia, which can cause cardiac complications.
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the physician.
- B. Record the reading as the only action.
- C. Turn the client and recheck the reading.
- D. Place the client supine.
Correct Answer: A
Rationale: An ICP of 66 mmHg is dangerously high (normal <20 mmHg), requiring immediate physician notification for intervention. Recording only (B), turning (C), or supine positioning (D) delays critical action.