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nclex 6 respiratory
1. 1 - ✔✔The nurse is preparing to perform nasotracheal suctioning on a client. The nurse places the
client's bed in which position to effectively perform this procedure? Refer to figure.
1. 1
2. 2
3. 3
4. 4
1. 10 seconds
Rationale:
During suctioning, the nurse should apply suction during the withdrawal of the catheter for a period of
5 to 10 seconds. Suction applied longer than this can cause hypoxia in the client. - ✔✔The nurse is
planning to suction a client through a tracheostomy tube. Which is the amount of time for application
of suction during withdrawal of the catheter?
%
1. 10 seconds
2. 25 seconds
3. 30 seconds
4. 35 seconds
1. Abdominal distention
Rationale:
Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and the
esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the
stomach, causing abdominal distention. It also can cause aspiration of gastric contents. Option 2 may
indicate an infection. Option 3 may indicate the need for more frequent suctioning. Option 4 may
indicate an obstruction of some sort or the presence of bronchoconstriction. - ✔✔The nurse is caring
for a client at home who has had a tracheostomy tube for several months. The nurse monitors the
client for complications associated with the long-term tracheostomy and suspects tracheoesophageal
fistula if which observation is noted for the client?
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1. Abdominal distention
2. Purulent drainage around the tracheotomy site
3. Excessive secretions from the tracheotomy site
4. Inability to pass a suction catheter through the tracheotomy
1. Activities should be resumed gradually.
3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
4. Respiratory isolation is not necessary because family members have already been exposed.
5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags.
Rationale:
The nurse should provide the client and family with information about tuberculosis and allay concerns
about the contagious aspect of the infection. The client is reassured that after 2 to 3 weeks of
%
medication therapy, it is unlikely that the client will infect anyone. The client is also informed that
activities should be resumed gradually. The client and family are informed that respiratory isolation is
not necessary, because family members have already been exposed. The client is instructed about
thorough hand washing and to cover the mouth and nose when coughing or sneezing and confi -
✔✔The nurse is preparing a list of home care instructions for the client who has been hospitalized
and treated for tuberculosis. Which instructions should the nurse reinforce? Select all that apply.
1. Activities should be resumed gradually.
2. Avoid contact with other individuals, except family members, for at least 6 months.
3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
4. Respiratory isolation is not necessary because family members have already been exposed.
5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags.
6.
When one sputum culture is negative, the client is no longer considered infectious and can usually
return to his or her former employment.
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1. Apply suction for up to 10 to 15 seconds.
2. Hyperoxygenate the client before suctioning.
5. Apply intermittent suction while rotating and withdrawing the catheter.
6. Advance the catheter until resistance is met and then pull the catheter back 1 cm.
Rationale:
Intermittent suction is applied while rotating the catheter for 10 to 15 seconds. The nurse should
hyperoxygenate the client with a resuscitator bag/Ambu-bag connected to an oxygen source before
suctioning because suction depletes the client's oxygen supply (option 2). The catheter should be
inserted gently until resistance is met or the client coughs, then pulled back 1 cm or ½ inch.
Intermittent suction is applied while rotating and withdrawing the catheter. Option 3 is incorrect
because wall suction should be set to 80 to 120 mm Hg. Pressure set at a higher level can cause
trauma to respiratory tract tissues. Strict asepsis needs to be maintained, - ✔✔The nurse is
preparing to suction an adult client through the client's tracheostomy tube. Which interventions should
the nurse perform for this procedure? Select all that apply.
%
1. Apply suction for up to 10 to 15 seconds.
2. Hyperoxygenate the client before suctioning.
3. Set the wall suction unit pressure at 160 mm Hg.
4. Apply suction while gently inserting the catheter.
5. Apply intermittent suction while rotating and withdrawing the catheter.
6. Advance the catheter until resistance is met and then pull the catheter back 1 cm.
1. Avoid foods that are highly seasoned.
Rationale:
The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to
soothe the painful throat. Milk and milk products are avoided because they tend to increase mucous
production. Foods that are highly seasoned are irritating to the throat and should be avoided, and the
client should be instructed to drink 2000 to 3000 mL of fluid daily, unless contraindicated. - ✔✔A
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clinic nurse is reinforcing instructions to a client with a diagnosis of pharyngitis. Which intervention
should the client be encouraged to perform?
1. Avoid foods that are highly seasoned.
2. Restrict fluid intake to 1000 mL daily.
3. Drink warm herbal tea throughout the day.
4. Substitute hot chocolate in place of coffee.
1. Avoid hot fluids.
2. Avoid rough foods.
4. Rest for the next 24 hours.
Rationale:
Following tonsillectomy, the client is instructed to advance the diet from cool clear liquids to full
liquids. Hot fluids and carbonated beverages should be avoided because they may be irritating to the
%
throat. Milk and milk products are avoided because they may cause the client to cough, which can
hurt the surgical site. Rough foods and snacks such as raw fruits or vegetables should be avoided for
10 days to protect the scab that forms over the operative site and to prevent bleeding. The client
should be instructed to rest in bed or on a couch for 24 hours after the surgical procedure and
gradually resume full activity. - ✔✔The nurse is assisting in preparing a list of instructions for an adult
client who is being discharged following a tonsillectomy. Which instructions should the nurse include
in the list? Select all that apply.
1. Avoid hot fluids.
2. Avoid rough foods.
3. Consume milk products.
4. Rest for the next 24 hours.
5. Consume carbonated beverages.
6. Eat ice cream to soothe the throat.
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