The nurse cares for a client
with a cuffed tracheostomy
tube. Before performing oral
care, the nurse notes that the
client's tracheostomy cuff is
inflated. Which of the following
is the MOST appropriate action
for
...
The nurse cares for a client
with a cuffed tracheostomy
tube. Before performing oral
care, the nurse notes that the
client's tracheostomy cuff is
inflated. Which of the following
is the MOST appropriate action
for the nurse to take?
1. Leave the cuff inflated and
suction through the
tracheostomy.
2. Deflate the cuff and suction
through the tracheostomy
tube.
3. Inflate the cuff pressure to
40 mm Hg before suctioning.
4. Adjust the wall suction
pressure to 160 to 180 mm Hg
before suctioning.
1) CORRECT - Implementation: outcome desired;
cuff inflation decreases the risk of aspiration; cuff
position and pressure should be assessed
frequently; swallowing and breathing will cause
tracheostomy tube movement
2) Implementation: outcome not desired;
accumulated oral secretions above the cuff will
drain into the bronchi; increased risk of infection
3) Implementation: outcome not desired; cuff
pressure should be less than 20 mm Hg (25 cm
H2O); risk of trauma to trachea with higher
pressures
4) Implementation: outcome not desired; increases
the risk of trauma to lower airways
3/16/2021 Kaplan NCLEX Readiness Exam Flashcards | Quizlet
https://quizlet.com/477609184/kaplan-nclex-readiness-exam-flash-cards/ 2/139
A young adult brings a friend
to the emergency department
and states that the friend has
been using heroin. Which
action by the nurse is the
MOST appropriate?
1. Assess pupil size and
reactivity.
2. Assess oxygen saturation
levels.
3. Palpate dorsalis pedis
pulses.
4. Ask the client if he knows
today's date.
1) Assessment: outcome not priority but may be
appropriate; pinpoint pupils are a sign of heroin
overdose
2) CORRECT - Assessment: outcome priority;
shallow respirations seen; impaired alveolar gas
exchange and possible respiratory arrest
3) Assessment: outcome not priority; most
important to assess airway and breathing
4) Assessment: outcome not priority but may be
appropriate; drowsiness and euphoria may be seen;
not priority
The client tells the clinic nurse
that the client is thinking about
using nicotine polacrilex
(Nicorette). Which question is
MOST important for the nurse
to ask?
1. "Have you tried other
methods to stop smoking?"
2. "How long have you been
smoking?"
3. "Have you ever had chest
pain?"
4. "Do you have a partial dental
bridge?"
1) Assessment: outcome not priority but may be
appropriate; can be asked as part of assessment
2) Assessment: outcome not priority but may be
appropriate; should be assessed for further
teaching
3) CORRECT - Assessment: outcome priority; action
of nicotine is vasoconstriction; increases heart rate
and myocardial oxygen consumption; increased risk
of angina and myocardial infarction
4) Assessment: outcome may be appropriate but
not priority; gum is place between cheek and gums;
may stain dental work
[Show More]
