MED-SURGE (UPPER RESPIRATORY EAQ) EXAM QUESTIONS
AND ANSWERS VERIFIED
Which action should the nurse implement when performing tracheal suctioning
for a client with a tracheostomy?
Administration of 100% oxygen for a few minutes before suctioning reduces the risk of
hypoxia, the major complication of suctioning. Suction is applied as the catheter is
withdrawn, not during insertion, to prevent hypoxia. Tracheostomy cuffs are indicated
when the client is on mechanical ventilation. Although a dilute solution may be instilled
into a tracheostomy, this requires a health care provider's prescription.
A client's respiratory status deteriorates, and endotracheal intubation and
positive pressure ventilation are instituted. What is the nurse's most immediate
intervention at this time?
Assess the client's response to the interventions.
Several days after a client had a total laryngectomy, the health care provider
prescribes a progressive diet as tolerated. What should the nurse do?
Keep suction apparatus readily available in case excessive respiratory secretions occur.
Initial attempts at oral feeding may cause a choking feeling that may produce severe
coughing that raises secretions. Effective coughing is difficult because with a
laryngectomy there is no glottis to close to assist with an expulsive cough. Excessive
, secretions may block the airway and must be removed by suctioning. Swallowing does
not have an adverse effect on the suture line; a nasogastric tube is not used because it
can traumatize the suture line. A progressive diet is started with liquids, not pureed
foods. Airway patency is the priority, not administering medication for pain.
A client who had a laryngectomy for cancer of the larynx is being transferred
from the postanesthesia care unit to a surgical unit. Which is the most important
equipment that the nurse should place in the client's room?
Suction Equipment
Respiratory complications can occur after a laryngectomy is performed because of the
production of excessive secretions, edema of the glottis, or injury to the recurrent
laryngeal nerve. Also, after a laryngectomy the client will be unable to cough effectively
to raise secretions. Although writing supplies along with a picture board are helpful for
promoting communication, they are not the priority. A tracheostomy set is unnecessary.
When a laryngectomy is performed a permanent stoma in the trachea is surgically
created and a laryngectomy tube is in place. An additional sterile laryngectomy tube
should be kept at the bedside. A client with a tracheal stoma cannot use an incentive
spirometer.
A client returns from surgery after a total laryngectomy with a laryngectomy tube
in the permanent stoma. In which position should the nurse place this client to
facilitate respirations and promote comfort?
AND ANSWERS VERIFIED
Which action should the nurse implement when performing tracheal suctioning
for a client with a tracheostomy?
Administration of 100% oxygen for a few minutes before suctioning reduces the risk of
hypoxia, the major complication of suctioning. Suction is applied as the catheter is
withdrawn, not during insertion, to prevent hypoxia. Tracheostomy cuffs are indicated
when the client is on mechanical ventilation. Although a dilute solution may be instilled
into a tracheostomy, this requires a health care provider's prescription.
A client's respiratory status deteriorates, and endotracheal intubation and
positive pressure ventilation are instituted. What is the nurse's most immediate
intervention at this time?
Assess the client's response to the interventions.
Several days after a client had a total laryngectomy, the health care provider
prescribes a progressive diet as tolerated. What should the nurse do?
Keep suction apparatus readily available in case excessive respiratory secretions occur.
Initial attempts at oral feeding may cause a choking feeling that may produce severe
coughing that raises secretions. Effective coughing is difficult because with a
laryngectomy there is no glottis to close to assist with an expulsive cough. Excessive
, secretions may block the airway and must be removed by suctioning. Swallowing does
not have an adverse effect on the suture line; a nasogastric tube is not used because it
can traumatize the suture line. A progressive diet is started with liquids, not pureed
foods. Airway patency is the priority, not administering medication for pain.
A client who had a laryngectomy for cancer of the larynx is being transferred
from the postanesthesia care unit to a surgical unit. Which is the most important
equipment that the nurse should place in the client's room?
Suction Equipment
Respiratory complications can occur after a laryngectomy is performed because of the
production of excessive secretions, edema of the glottis, or injury to the recurrent
laryngeal nerve. Also, after a laryngectomy the client will be unable to cough effectively
to raise secretions. Although writing supplies along with a picture board are helpful for
promoting communication, they are not the priority. A tracheostomy set is unnecessary.
When a laryngectomy is performed a permanent stoma in the trachea is surgically
created and a laryngectomy tube is in place. An additional sterile laryngectomy tube
should be kept at the bedside. A client with a tracheal stoma cannot use an incentive
spirometer.
A client returns from surgery after a total laryngectomy with a laryngectomy tube
in the permanent stoma. In which position should the nurse place this client to
facilitate respirations and promote comfort?
