Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?

Correct Answer: A

Rationale: Suctioning a tracheostomy tube is a procedure that requires proper technique to prevent complications. Hyperventilating James with 100% oxygen before and after suctioning indicates that Wilma is committing an error. The correct approach is to provide pre-oxygenation with 100% oxygen for at least two minutes before suctioning to prevent hypoxemia. However, hyperventilation with 100% oxygen can lead to oxygen toxicity, which can be harmful to the patient. The other options, instilling normal saline to loosen secretions, applying suction during catheter withdrawal, and suctioning the client every hour are appropriate techniques when performing tracheostomy tube suctioning.

Correct Answer: C

Rationale: Puffiness at the site is the symptom that most likely indicates that an infusion is infiltrated. Infiltration occurs when the IV fluid leaks into the surrounding tissues instead of entering the vein. This can lead to swelling and puffiness at the site as the fluid accumulates in the tissue. Redness, pain, and exudate at the site are also common signs of infiltration, but puffiness specifically points towards the fluid accumulating outside the vein. If infiltration is suspected, it is important to stop the infusion, remove the IV catheter, and apply appropriate treatment based on the severity of the infiltration.

Correct Answer: D

Rationale: When implementing interventions for trauma to the upper airway, it is crucial for the nurse to assess for the presence of laryngospasm. Laryngospasm is a sudden spasm of the vocal cords that may cause difficulty breathing and in severe cases, complete airway obstruction. It is a serious and potentially life-threatening complication that can occur following upper airway trauma. Therefore, prompt recognition and treatment of laryngospasm are essential to ensure adequate oxygenation and ventilation for the client. Pain when talking, increased nasal swelling, and burning in the throat may also be symptoms encountered in upper airway trauma, but the presence of laryngospasm signifies a more critical condition requiring immediate intervention.

Correct Answer: C

Rationale: When caring for a client with influenza, immediate recognition of respiratory distress is crucial. Influenza can lead to respiratory complications such as pneumonia, which may result in respiratory distress. Early detection of symptoms such as increased respiratory rate, shortness of breath, and chest pain can help in providing prompt intervention and preventing further complications. Therefore, the nursing intervention involved in caring for a client with influenza is to closely monitor the respiratory status and quickly recognize any signs of respiratory distress. This proactive approach can potentially save the client's life and improve outcomes.

Correct Answer: B

Rationale: Anorexia, or loss of appetite, is a common side effect of digoxin. It can lead to weight loss, weakness, and fatigue. Monitoring for anorexia is important because it may indicate digoxin toxicity, which can be serious and require intervention. Skin flushing is not a common side effect of digoxin. Hypertension is also not associated with digoxin use. Constipation is generally not a common side effect of digoxin. Therefore, anorexia is the assessment that indicates a potential side effect of digoxin that requires follow-up.