The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the client?
1. The ability to cough
2. Filtration and humidification of inspired air
3. The sneeze reflex initiated by irritants in the nasal passages
4. Decrease in oxygen-carrying capacity of the trachea
Correct Answer: 2
Rationale 1: The client is able to cough.
Rationale 2: When the nasal passages are bypassed as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages is also bypassed.
Rationale 3: The client can sneeze.
Rationale 4: There is no decrease in the oxygen-carrying capacity of the trachea.
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