While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required
A) every 2 hours.
B) when adventitious breath sounds are auscultated.
C) to prevent the patient from coughing.
D) to stimulate the cough reflex.
Ans: B
Feedback: It is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa.
You might also like to view...
During the termination phase, which of the following occurs?
A) Encouraging independence in getting along with others B) Planning of outcomes and goals C) Evaluating the effectiveness of changes D) Building trust and establishing roles
Which lists the services needed by the person?
a. Care plan b. Service plan c. Medication record d. Medical record
Describe the effects that nitrates have on the body.
What will be an ideal response?
The nurse is explaining the difference between Bell's palsy and trigeminal neuralgia to a nursing assistant. What should the nurse include as characteristics of Bell's palsy? (Select all that apply.)
a. Drooling b. Facial droop c. Sudden onset d. Airflow sensitivity e. Sensitivity to temperature f. Loss of taste over anterior part of tongue