The nurse knows that the most effective method for suctioning a patient with a tracheostomy tube is to

Correct Answer: D

Rationale: The most effective method for suctioning a patient with a tracheostomy tube is to apply suction while gently rotating and inserting the catheter. This technique helps to safely remove secretions without damaging the tracheal mucosa or causing trauma. By rotating and inserting the catheter gently, the nurse ensures that the suctioning is effective while minimizing the risk of injury. This method also helps to clear secretions more efficiently and can improve the patient's respiratory status. It is important to follow proper suctioning techniques to prevent complications and promote optimal patient outcomes.

Correct Answer: B

Rationale: In this scenario, option B, "Restlessness and confusion," requires immediate action because it suggests a potential oxygen saturation issue despite the oxygen therapy being administered. Restlessness and confusion can indicate hypoxia, a serious condition where the body is not receiving enough oxygen. This finding could be an early sign of respiratory distress and requires prompt assessment and intervention to prevent further deterioration. Option A, "Dry nasal mucosa," is a common side effect of oxygen therapy and can be managed with humidification. While uncomfortable, it does not pose an immediate threat to the client's health. Option C, "Decreased respiratory rate to 12 breaths/min," could be concerning if accompanied by other symptoms of respiratory distress. However, a respiratory rate of 12 breaths/min within a normal range does not necessarily indicate a critical issue in isolation. Option D, "Oxygen saturation of 96%," is within the normal range for oxygen saturation and indicates adequate oxygenation. While continuous monitoring is essential, a saturation of 96% does not require immediate action unless there are other concerning symptoms present. Educationally, this question highlights the importance of recognizing early signs of hypoxia in clients receiving oxygen therapy. It emphasizes the need for nurses to prioritize critical thinking and prompt assessment to ensure the safety and well-being of their clients. By understanding the significance of different clinical findings, nurses can provide timely interventions and prevent potential complications in their practice.

Correct Answer: C

Rationale: In managing a client prescribed with a bronchodilator and a corticosteroid inhaler, the nurse should provide essential education to ensure optimal therapeutic outcomes. The correct answer, option C, instructs the client to rinse their mouth after using the corticosteroid inhaler. This is crucial because corticosteroids can increase the risk of oral fungal infections, so rinsing the mouth helps prevent this complication. Option A, instructing to use the corticosteroid inhaler first, is incorrect because bronchodilators should be used before corticosteroids to open the airways and allow better penetration of the corticosteroid medication. Option B, waiting 5 minutes between using the two inhalers, is not recommended as there is no specific time interval requirement between using bronchodilators and corticosteroids. Option D, not using the bronchodilator if symptoms improve, is also incorrect as bronchodilators provide immediate relief of symptoms and should be used as needed regardless of symptom improvement. In an educational context, it is important for nurses to emphasize the correct sequence of using inhalers, the importance of rinsing the mouth after corticosteroid inhaler use, and the need for continued bronchodilator use as prescribed for effective symptom management in clients with respiratory conditions. This knowledge empowers clients to properly manage their medications and reduce the risk of adverse effects.

Correct Answer: B

Rationale: In assessing a client with suspected pneumothorax, the finding most indicative of this condition is decreased breath sounds on the affected side (Option B). This is because a pneumothorax involves air accumulating in the pleural space, causing lung collapse. As a result, breath sounds are diminished or absent over the affected area. Option A, dullness on percussion, is associated with conditions like pleural effusion, not pneumothorax. Option C, barrel-shaped chest, is typically seen in patients with chronic obstructive pulmonary disease (COPD). Option D, cyanosis of lips and fingertips, is a sign of hypoxia and is not specific to pneumothorax. In an educational context, understanding the specific clinical manifestations of pneumothorax is crucial for nurses to provide timely and accurate care. Recognizing decreased breath sounds in a patient with suspected pneumothorax can prompt immediate intervention, such as notifying the healthcare provider for further evaluation and treatment. This knowledge enhances patient safety and outcomes in clinical practice.

Correct Answer: A

Rationale: In this scenario, option A, "Decreased wheezing on auscultation," suggests that the albuterol medication is effective for the client with asthma. Wheezing is a common symptom of asthma caused by airway constriction and inflammation. Albuterol is a bronchodilator that works to relax the airway muscles, leading to improved airflow and decreased wheezing. Therefore, a reduction in wheezing indicates that the medication is effectively dilating the airways and improving the client's breathing. Options B, C, and D are incorrect. An increased heart rate (option B) could indicate a side effect of albuterol, but it does not necessarily indicate the effectiveness of the medication in treating asthma. A decreased oxygen saturation (option C) would be a concerning finding, as it suggests inadequate oxygenation despite treatment. Mild hand tremors (option D) are a known side effect of albuterol but do not directly reflect the medication's effectiveness in treating asthma. Educationally, it is crucial for nurses to understand the expected outcomes and responses to specific medications used in treating respiratory conditions like asthma. Monitoring for clinical indicators of effectiveness, such as improved respiratory function like decreased wheezing, helps nurses assess the client's response to treatment and make informed decisions about ongoing care and interventions. This knowledge enhances patient safety and improves overall health outcomes for individuals with asthma.