Respiratory - Saunders NCLEXPN Examination 6th Edition With Rationales 2024 Graded A+

Respiratory -
Saunders NCLEXPN Examination
6th Edition With
Rationales 2024
Graded A+
The nurse is suctioning an adult client through a
tracheostomy tube. During the procedure, the nurse
notes that the client's oxygen saturation by pulse
oximetry is 89%. Which action should the nurse
implement? - ANS-Stop the suctioning procedure.
(Rationale)
The nurse should monitor the client's heart rate and
pulse oximetry during suctioning to assess the client's
tolerance of the procedure. Oxygen desaturation below
90% indicates hypoxia. If hypoxia occurs during
suctioning, the nurse stops the suctioning procedure.
Using the 100% oxygen delivery system, the client is
reoxygenated until baseline parameters are achieved.
The size of the catheter should not exceed half of the size
of the tracheal lumen. In adults, the standard catheter
size is 12 to 14 French. Adequate catheter size facilitates
efficient removal of secretions without causing
hypoxemia.
The nurse is performing nasopharyngeal suctioning on a
client and suddenly notes the presence of bloody
secretions. Which action should the nurse implement? -
ANS-Check the amount of suction pressure being applied.
(Rationale)
The return of bloody secretions is an unexpected
outcome related to suctioning. If this occurs, the nurse
should first assess the client and then determine the
amount of suction pressure being applied. The amount of
suction pressure may need to be decreased. The nurse
also needs to be sure that intermittent suction and
catheter rotation are being done during suctioning.
Continuing with the suctioning or vigorous suctioning
through the mouth will cause increased trauma and thus
increased bleeding. Suctioning is normally performed on
clients who are unable to expectorate secretions.
Therefore, it is unlikely that the client will be able to
cough out the bloody secretions.
The nurse is caring for a client with laryngitis. Which
interventions should the nurse implement? Select all that
apply. - ANS-Discourage smoking
Use a room humidifier
Use lozenges that contain a topical anesthetic agents
(Rationale)
Smoking irritates the throat so the client is discouraged
from smoking. A humidifier will prevent a dry nose and
throat. Lozenges with a topical anesthetic agent will
decrease throat discomfort. Voice rest means not talking
at all, even whispering. There should be a sign on the
intercom indicating voice rest and going to the client's
room.
The nurse is reading the results of a Mantoux tuberculin
skin test on a client with no documented health
problems. The site has no induration and a 1-mm area of
ecchymosis. Which interpretation should the nurse make
of these results? - ANS-Negative
(Rationale)
A positive Mantoux tuberculin skin test reading has an
induration measuring 10 mm or more in diameter and
indicates exposure to tuberculosis. A small area of
ecchymosis is insignificant and is probably related to
injection technique. Therefore, the remaining options are
incorrect.
A client has a chest tube that is attached to a