NCLEX PN Exam Practice Test Related

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The nurse is caring for a 6-month-old client who has a new tracheostomy. Which of the following findings would indicate that the client's airway requires suctioning? Select all that apply.

  • A. Audible gurgling
  • B. Heart rate of 110/min
  • C. Increased irritability
  • D. Oxygen saturation of 88%
  • E. Respiratory rate of 30/min
Correct Answer: A,C,D

Rationale: Audible gurgling, irritability, and low oxygen saturation (88%) indicate airway obstruction or secretions requiring suctioning. Normal heart rate (110/min) and respiratory rate (30/min) for a 6-month-old do not necessitate suctioning.