Choice A rationale:

The goal of oxygen therapy is not to provide the highest fraction of inspired oxygen (FiO2) possible. This approach can be harmful because excessively high FiO2 levels can lead to oxygen toxicity and other side effects, especially in patients with certain conditions like chronic obstructive pulmonary disease (COPD).

Choice B rationale:

The goal of oxygen therapy is to use the lowest FiO2 that achieves an acceptable blood oxygen level without harmful side effects. This approach is known as titrating the oxygen therapy to the patient's needs and helps prevent potential complications associated with excessive oxygen administration.

Choice C rationale:

Maintaining a constant FiO2 regardless of the patient's breathing pattern is not the goal of oxygen therapy. In some cases, patients may require varying FiO2 levels based on their respiratory status, so it is essential to adjust the oxygen delivery accordingly.

Choice D rationale:

Delivering a fixed amount of oxygen that is independent of the patient's condition is not the goal of oxygen therapy. Oxygen therapy should be individualized and tailored to the patient's specific needs to optimize its effectiveness and safety.

Choice A rationale:

Nasal cannula is a low-flow oxygen delivery system because the oxygen flow rate is relatively low and the delivered oxygen is mixed with room air before reaching the patient's lungs.

Choice B rationale:

The simple face mask is a low-flow oxygen delivery system. It delivers oxygen at a fixed flow rate and allows room air to mix with the delivered oxygen.

Choice C rationale:

Venturi mask is not a low-flow oxygen delivery system. It is a high-flow system that provides a specific and precise FiO2, making it suitable for patients with chronic respiratory conditions.

Choice D rationale:

The non-rebreather mask is not a low-flow oxygen delivery system. It is a high-flow system that is used when the patient requires a high FiO2, close to 100%, to ensure adequate oxygenation.

Choice E rationale:

Aerosol mask is a low-flow oxygen delivery system that delivers oxygen mixed with aerosolized medication. The flow rate is relatively low compared to high-flow systems.

Choice A rationale:

Switching to a simple face mask is not the appropriate intervention for nasal dryness and irritation. A simple face mask covers the nose and mouth, and it may not provide enough relief for nasal dryness as the oxygen flow is still directed towards the nose.

Choice B rationale:

Increasing the flow rate of oxygen will not directly improve humidity. Nasal dryness and irritation are often caused by the lack of moisture in the delivered oxygen. Increasing the flow rate may worsen the issue.

Choice C rationale:

Assessing the patient's nares for patency and skin integrity is the appropriate intervention. Nasal dryness and irritation can be caused by inadequate humidification of the oxygen. Checking the patency of the nares and the condition of the skin can help identify any issues that may be contributing to the discomfort.

Choice D rationale:

Reassuring the patient that nasal dryness is a normal side effect is not sufficient. While nasal dryness can be a common side effect of using a nasal cannula, it is essential to address the issue and provide appropriate interventions to alleviate the discomfort and prevent complications.

Choice A rationale:

Increasing the flow rate of oxygen may not be the priority action because the patient's shortness of breath could be due to a problem with the mask itself, rather than the amount of oxygen being delivered. Before making any adjustments to the oxygen flow rate, it is essential to assess the equipment's integrity.

Choice B rationale:

This is the priority action because a partial rebreather mask relies on the patient's exhaled breath to partially fill the reservoir bag. If the mask bag does not remain inflated during both inspiration and expiration, the patient may not be receiving the appropriate oxygen concentration, leading to increased shortness of breath. Checking the mask bag ensures that the mask is functioning correctly and delivering the intended oxygen concentration.

Choice C rationale:

Switching the patient to a non-rebreather mask for higher oxygen delivery is not the priority action in this scenario. The non-rebreather mask is used when high oxygen concentrations are required, such as in emergencies or when a patient's condition requires immediate intervention. However, the priority at this moment is to assess the current equipment's effectiveness before considering a change in oxygen delivery method.

Choice D rationale:

Reassuring the patient that shortness of breath is common with this type of mask is not appropriate without first addressing the issue at hand. The nurse should first assess the mask's functionality to ensure it is working correctly and providing the appropriate oxygen concentration before addressing the patient's concerns.

Choice A rationale:

Although a tracheostomy collar provides oxygen directly to the trachea, the advantage specified in the question is related to the ability to breathe room air when disconnected from the oxygen source.

Choice B rationale:

This is the correct answer because a tracheostomy collar has an opening that allows the patient to breathe room air when the oxygen source is disconnected. This feature enables the patient to participate in activities without continuous oxygen delivery, promoting mobility and reducing the feeling of being tethered to an oxygen supply.

Choice C rationale:

A tracheostomy collar does not provide the highest fraction of inspired oxygen (FiO2) among low-flow systems. High-flow systems, such as non-rebreather masks or venturi masks, typically provide the highest FiO2.

Choice D rationale:

A tracheostomy collar does not deliver a fixed amount of oxygen independent of the patient's breathing pattern. Instead, it provides supplemental oxygen in response to the patient's inspiratory effort, which is a characteristic of low-flow oxygen delivery systems.

Choice A rationale:

Nasal cannula delivers low to moderate concentrations of oxygen and may not be effective for a client with thick secretions, dry mucous membranes, or upper airway edema. Additionally, the nasal cannula may not provide sufficient humidification to alleviate these conditions.

Choice B rationale:

The simple face mask is not ideal for a client with thick secretions, dry mucous membranes, or upper airway edema as it may not provide enough humidification and could be uncomfortable for the patient.

Choice C rationale:

A partial rebreather mask also may not be the most appropriate choice for this client as it has a reservoir bag that may not adequately humidify the oxygen, leading to discomfort and potential worsening of dry mucous membranes.

Choice D rationale:

The aerosol mask is the most appropriate choice because it delivers humidified oxygen in the form of small aerosol particles, which can help alleviate thick secretions, moisturize dry mucous membranes, and reduce upper airway edema. This mask is beneficial for patients who require higher humidity levels to maintain airway patency and comfort.

Choice A rationale:

Nasal cannula delivers oxygen through two small prongs placed in the patient's nostrils. While it is a commonly used and well-tolerated device, the FiO2 delivered can vary significantly depending on the patient's breathing pattern and respiratory rate. Thus, it does not provide the most precise and consistent FiO2.

Choice B rationale:

Simple face masks cover the nose and mouth and can provide higher FiO2 levels compared to nasal cannulas. However, the FiO2 delivered still depends on the patient's breathing pattern and the mask's fit, making it less precise and consistent than other options.

Choice C rationale:

Venturi masks are designed to deliver a specific and accurate FiO2, regardless of the patient's breathing pattern. These masks have adjustable ports to control the mix of air and oxygen, providing precise oxygen concentrations.

Choice D rationale:

Non-rebreather masks have one-way valves and a reservoir bag to deliver higher concentrations of oxygen. Although they can provide high FiO2 levels, the delivered concentration can vary based on the patient's breathing pattern and the mask's fit.

Choice A rationale:

Venturi masks are not typically used with tracheostomy patients, as they are more suitable for patients with intact upper airways.

Choice B rationale:

Tracheostomy collars are specifically designed for patients with tracheostomies. They provide oxygen directly to the tracheostomy tube, making them appropriate for weaning tracheostomized patients from mechanical ventilation.

Choice C rationale:

T-piece adapters are commonly used for patients with tracheostomies to deliver oxygen. They are simple devices that deliver oxygen directly to the tracheostomy tube.

Choice D rationale:

Aerosol masks are not specifically designed for tracheostomy patients and may not provide adequate oxygen delivery for them.

Choice E rationale:

Mechanical ventilators are not an oxygen delivery device; instead, they are used to provide mechanical ventilation support to the patient and can incorporate various oxygen delivery systems.

Choice A rationale:

At a flow rate of 4 L/min, oxygen therapy through a nasal cannula can increase the risk of oxygen toxicity, especially if used for prolonged periods. Oxygen toxicity can cause damage to the lungs and other organs.

Choice B rationale:

Carbon dioxide retention is not a common complication at this flow rate. It may occur in patients with severe chronic obstructive pulmonary disease (COPD) at higher oxygen flow rates.

Choice C rationale:

Nasal dryness is a common but relatively minor complication of oxygen therapy via nasal cannula. It can cause discomfort but is not a severe concern.

Choice D rationale:

Fire hazard is not directly related to the use of a nasal cannula but rather to the use of oxygen in the presence of flammable materials or near open flames. It is a concern for all oxygen delivery devices, not specific to nasal cannulas.

Choice A rationale:

The nurse should use a Venturi mask for a client with COPD requiring a precise concentration of oxygen. The Venturi mask delivers a specific oxygen concentration by mixing oxygen with room air through a venturi effect, ensuring accurate and consistent oxygen delivery.

Choice B rationale:

The non-rebreather mask is not the best choice for a client requiring a precise oxygen concentration. It is used for short-term, high-flow oxygen therapy and is not adjustable, making it unsuitable for precise oxygen delivery.

Choice C rationale:

The aerosol mask is used for delivering humidified oxygen and is not designed to deliver precise oxygen concentrations like the Venturi mask.

Choice D rationale:

The simple face mask is also not the best choice for a precise oxygen concentration. It delivers higher concentrations of oxygen but lacks the ability to fine-tune the delivered oxygen percentage like the Venturi mask.

Choice E rationale:

The tracheostomy collar is used for clients with a tracheostomy and does not provide precise oxygen concentrations like the Venturi mask.

Choice A rationale:

Refilling the oxygen tank based on the client's perception of it feeling light and empty is not a reliable method, as it may lead to running out of oxygen unexpectedly.

Choice B rationale:

The nurse should instruct the client to refill the oxygen tank when the pressure gauge reads below 500 psi. This is a standardized method to ensure the client does not run out of oxygen, as the pressure gauge provides an accurate measure of the remaining oxygen in the tank.

Choice C rationale:

Refilling the tank when a hissing sound is heard from the valve is not a valid method for determining the need for a refill and may result in running out of oxygen.

Choice D rationale:

Waiting for an alarm sound from the regulator to refill the tank is not recommended, as the tank could run out of oxygen before the alarm activates.

Choice A rationale:

Impaired gas exchange is assessed during the "Assessment”. phase of the nursing process. The nurse gathers data on the client's respiratory rate, cyanosis, and dyspnea to determine the presence of impaired gas exchange.

Choice B rationale:

Diagnosis in the nursing process involves identifying the client's health problems based on the assessment data. It does not specifically address impaired gas exchange during this phase.

Choice C rationale:

Planning involves setting goals and outcomes for the client's care. While addressing impaired gas exchange may be part of the plan, it is not the phase in which the nurse determines the client's gas exchange status.

Choice D rationale:

Evaluation is the phase of the nursing process where the nurse assesses the client's response to interventions and determines the effectiveness of the care provided. It does not directly relate to identifying impaired gas exchange.

SaO2 88%.

Choice A rationale:

A PaO2 of 80 mmHg is not an appropriate indicator of oxygen therapy effectiveness. While it's within the normal range (80-100 mmHg), it doesn't specifically reflect the effectiveness of oxygen therapy in this scenario.

Choice B rationale:

A SaO2 of 88% is an appropriate indicator of oxygen therapy effectiveness. Oxygen saturation (SaO2) measures the percentage of hemoglobin that is bound with oxygen. An SaO2 of 88% is considered an acceptable level, indicating that the oxygen therapy is effectively improving the oxygenation of the patient's blood.

Choice C rationale:

A respiratory rate (RR) of 32/min is not a specific indicator of oxygen therapy effectiveness. It may be within the normal range (12-20 breaths/min for adults), but it can be affected by various factors, not just oxygen therapy.

Choice D rationale:

A blood pressure (BP) of 160/90 mmHg is not a direct indicator of oxygen therapy effectiveness. While high blood pressure can be associated with hypoxia, it is not specific enough to determine the effectiveness of oxygen therapy in this case.

A humidifier.

Choice A rationale:

A humidifier is necessary to prevent complications in a patient receiving oxygen therapy via a tracheostomy collar. Oxygen delivered through a tracheostomy can dry out the airways and cause discomfort and potential complications. Adding humidity helps maintain airway moisture and prevents drying of the mucous membranes, reducing the risk of mucus plugs and irritation.

Choice B rationale:

A water seal is not necessary for a patient receiving oxygen therapy via a tracheostomy collar. Water seals are used in chest drainage systems to prevent air from entering the pleural space, but they are not relevant in this scenario.

Choice C rationale:

A suction catheter is used to clear secretions from the airway but is not directly related to preventing complications with oxygen therapy via a tracheostomy collar.

Choice D rationale:

A chest tube is not needed for a patient receiving oxygen therapy via a tracheostomy collar. Chest tubes are inserted to drain fluid or air from the pleural space, which is not applicable to this situation.

Keep the reservoir bag fully inflated at all times.

Choice A rationale:

In a partial rebreather mask, the reservoir bag should be kept fully inflated at all times to ensure the delivery of the highest possible oxygen concentration during inspiration. The bag collects oxygen during expiration, and the one-way valve prevents the exhaled gases from entering the bag. This way, the patient can inhale a mixture of oxygen from the reservoir and fresh oxygen flow.

Choice B rationale:

Breathing through the mouth and exhaling through the nose is not a necessary instruction for a patient using a partial rebreather mask. It doesn't directly impact the effectiveness of oxygen delivery.

Choice C rationale:

Adjusting the elastic strap to fit snugly around the face is not specific to ensuring effective oxygen delivery. It is a general guideline for mask fitting but doesn't directly affect oxygen administration.

Choice D rationale:

Removing the mask every 15 minutes to check the skin is not necessary and can disrupt the delivery of oxygen therapy. It's essential to maintain a consistent oxygen supply to the patient's lungs, and removing the mask frequently can compromise that. Checking the skin can be done periodically without removing the mask completely.

Choice A rationale:

The non-rebreather mask delivers the highest concentration of oxygen among low-flow systems. This is because the mask has a reservoir bag that fills with oxygen during inhalation, preventing the patient from breathing in room air and allowing them to receive a higher concentration of oxygen.

Choice B rationale:

The non-rebreather mask prevents the patient from rebreathing exhaled air. It has one-way valves that prevent exhaled air from being inhaled again, reducing the risk of carbon dioxide retention.

Choice E rationale:

The non-rebreather mask minimizes the risk of carbon dioxide retention. The presence of one-way valves in the mask ensures that the patient exhales carbon dioxide without rebreathing it, maintaining a proper oxygen and carbon dioxide exchange.

Choice C rationale:

The non-rebreather mask does not provide consistent and precise oxygen delivery. It is a low-flow system, and the delivered oxygen concentration may vary depending on the patient's breathing patterns and other factors.

Choice D rationale:

The non-rebreather mask does not allow room air to enter through exhalation ports. It is a closed system with one-way valves that only permit oxygen to flow into the mask during inhalation.

Questions.

Choice D rationale:

The nurse should connect the nasal cannula to a humidifier first. Dry and irritated nares are common side effects of oxygen therapy via nasal cannula, and using a humidifier adds moisture to the oxygen, reducing irritation and discomfort for the patient.

Choice A rationale:

Applying petroleum jelly to the nares is not the first action to take. It might provide temporary relief, but it is essential to address the root cause of dryness, which is the lack of moisture in the oxygen delivered.

Choice B rationale:

Increasing the flow rate of oxygen is not the first step because it may not address the dryness issue. It can lead to a higher concentration of oxygen, but it won't solve the problem of dry and irritated nares.

Choice C rationale:

Changing the nasal cannula to a face mask is not necessary to address the dryness. Face masks may not be well-tolerated by some patients, and it's better to try less invasive interventions first.

Choice A rationale:

The nurse should instruct the patient to avoid smoking or being near open flames while using oxygen. Oxygen supports combustion, and smoking or exposure to flames can lead to a fire hazard.

Choice C rationale:

Checking the position of the oxygen delivery device frequently is important to ensure proper oxygen delivery and avoid any displacement or obstruction that may compromise the therapy's effectiveness.

Choice D rationale:

Instructing the patient to report any signs of hypoxia (low oxygen levels) or hypercarbia (high carbon dioxide levels) to the provider is crucial for early detection of potential complications and appropriate management.

Choice E rationale:

Instructing the patient to adjust the flow rate of oxygen as needed allows them to respond to varying oxygen requirements, especially during activities or changes in their respiratory condition.

Choice B rationale:

Using cotton or wool clothing and bedding is not a recommended instruction for oxygen therapy. Synthetic materials are preferred as they are less likely to catch fire compared to cotton or wool.

Choice A rationale:

The nurse should not immediately check the patient's oxygen level with a finger device because the priority is to address the hissing sound from the mask and the patient's pale skin color, which could indicate inadequate oxygen delivery.

Choice B rationale:

Instructing the patient to breathe more deeply and slowly won't address the issue of the hissing sound and the possible oxygen delivery problem. The nurse should address the equipment issue first.

Choice C rationale:

This is the correct choice. The nurse should inform the patient that there is a problem with the mask, and it needs to be fixed promptly to ensure adequate oxygen therapy.

Choice D rationale:

Lowering the flow rate may not be appropriate until the nurse has assessed and resolved the problem with the mask. It's essential to troubleshoot the equipment first.

Choice A rationale:

The patient's PaO2 is 65 mmHg and SaO2 is 88%. PaO2 values below 80 mmHg and SaO2 below 90% are considered below normal ranges. Therefore, the patient's oxygen levels are not within the normal range for the condition.

Choice B rationale:

This is the correct choice. The patient's PaO2 and SaO2 levels indicate that they are not receiving enough oxygen, and additional oxygen therapy is needed.

Choice C rationale:

The patient's oxygen levels are low, not high. Providing less oxygen would worsen the situation.

Choice D rationale:

The patient's oxygen levels are affected by oxygen therapy, as they indicate that the current therapy is insufficient. Additional interventions are needed to improve oxygenation.

Choice A rationale:

Monitoring the patient's respiratory rate, depth, rhythm, and effort is crucial for assessing the effectiveness of oxygen therapy and ensuring proper oxygenation through the tracheostomy collar.

Choice B rationale:

Educating the patient on how to use and care for the tracheostomy collar is essential to ensure the patient's safety and compliance with the therapy.

Choice C rationale:

Implementing safety measures to prevent fire hazards from the oxygen source is crucial, especially when oxygen is delivered via tracheostomy collar, which may have increased oxygen flow rates.

Choice D rationale:

This is the correct choice. All the provided interventions (monitoring respiratory parameters, patient education, and safety measures) are essential components of the plan of care for a patient with a tracheostomy who requires oxygen therapy.

Choice A rationale:

Monitoring the patient's respiratory rate, depth, rhythm, and effort is crucial for assessing the effectiveness of oxygen therapy and ensuring proper oxygenation through the tracheostomy collar.

Choice B rationale:

Educating the patient on how to use and care for the tracheostomy collar is essential to ensure the patient's safety and compliance with the therapy.

Choice C rationale:

Implementing safety measures to prevent fire hazards from the oxygen source is crucial, especially when oxygen is delivered via tracheostomy collar, which may have increased oxygen flow rates.

Choice D rationale:

This is the correct choice. All the provided interventions (monitoring respiratory parameters, patient education, and safety measures) are essential components of the plan of care for a patient with a tracheostomy who requires oxygen therapy.

To assess lung sounds.

Choice A rationale:

Sterile suctioning is not performed to administer medications. Its primary purpose is to remove secretions and maintain a patent airway.

Choice B rationale:

Sterile suctioning is not done solely for promoting comfort. Its main goal is to clear the airway and prevent respiratory complications.

Choice C rationale:

The purpose of sterile suctioning is to assess lung sounds by removing excess secretions and mucus that may obstruct the airway. This helps in evaluating the patient's respiratory status and identifying any abnormal lung sounds.

Choice D rationale:

Sterile suctioning is not performed to monitor vital signs. Although vital signs may be monitored during the procedure, it is not the primary purpose of suctioning.

Choice A:

Plastic,.

Choice B:

Metal,.

Choice C:

Silicone, and Choice D:

Rubber.

Choice A rationale:

Plastic suctioning catheters are commonly used for sterile suctioning as they are disposable and come in various sizes for different patient needs.

Choice B rationale:

Metal suctioning catheters are also used for sterile suctioning and are often reusable, making them cost-effective for healthcare facilities.

Choice C rationale:

Silicone suctioning catheters are commonly used in sensitive situations or patients with latex allergies, as silicone is a non-allergenic material.

Choice D rationale:

Rubber suctioning catheters were commonly used in the past, but they are less common now due to the availability of more suitable materials like plastic and silicone.

Choice E rationale:

Glass suctioning catheters are not used for sterile suctioning due to the risk of breakage, which can lead to serious injuries and complications.

"I have been coughing up blood.”.

Choice A rationale:

Mild nasal congestion may be a common finding in many patients and does not necessarily contraindicate suctioning unless it significantly obstructs the airway.

Choice B rationale:

A sore throat may indicate local irritation, but it does not directly contraindicate suctioning unless there are other underlying complications.

Choice C rationale:

A history of coughing up blood (hemoptysis) suggests an ongoing bleeding disorder. Suctioning could exacerbate the bleeding, leading to further complications. The procedure should be avoided until the cause of hemoptysis is properly assessed and managed.

Choice D rationale:

Feeling lightheaded may be a common sensation during and after suctioning due to the stimulation of the gag reflex, but it does not necessarily contraindicate the procedure. It is essential to ensure adequate oxygenation and provide proper support during the procedure to minimize this discomfort.

Choice A rationale:

Epiglottitis is an inflammation of the epiglottis, which is a crucial structure in protecting the airway during swallowing. Suctioning in patients with a history of epiglottitis can be dangerous because it can cause further irritation and swelling of the epiglottis, potentially leading to airway obstruction and respiratory distress. Therefore, sterile suctioning is contraindicated in patients with a history of epiglottitis.

Choice B rationale:

Laryngeal edema refers to swelling of the larynx, which can also compromise the airway. While it is essential to monitor and manage laryngeal edema carefully, it is not an absolute contraindication for sterile suctioning. In some cases, suctioning may be necessary to maintain a patent airway, but it should be performed with caution and by experienced personnel.

Choice C rationale:

Difficulty clearing secretions is a common indication for sterile suctioning. Patients who have difficulty clearing their secretions may need suctioning to prevent the accumulation of mucus and maintain a clear airway. Therefore, this statement does not indicate a contraindication for the procedure.

Choice D rationale:

Using an artificial airway at night, such as a tracheostomy tube, indicates that the patient may require suctioning to maintain airway patency. While having an artificial airway increases the risk of infection and other complications, it is not a contraindication for sterile suctioning if clinically indicated.

Choice A rationale:

The most crucial measure to prevent cross-contamination during sterile suctioning is the use of personal protective equipment (PPE). PPE, including gloves, gown, mask, and eye protection, creates a barrier between the healthcare provider and the patient's respiratory secretions, reducing the risk of infection transmission.

Choice B rationale:

Proper disposal of waste materials is important for infection control, but it is not the most critical measure to prevent cross-contamination during sterile suctioning. While proper waste disposal is necessary to reduce the spread of infections, using PPE is more directly related to preventing cross-contamination during the procedure.

Choice C rationale:

Environmental cleaning of the suction device is essential for infection control, but it is not the most important measure to prevent cross-contamination during sterile suctioning. The immediate and direct protection provided by PPE is more effective in reducing the risk of transmission during the procedure.

Choice D rationale:

Performing hand hygiene before and after the procedure is vital for infection control, but it is not the most crucial measure to prevent cross-contamination during sterile suctioning. While hand hygiene is essential for reducing the spread of infections, using PPE provides an additional layer of protection during the procedure.

Choice D rationale:

When suctioning patients with an artificial airway, using disposable plastic catheters is preferred to reduce the risk of infection. Disposable catheters are single-use and discarded after each procedure, minimizing the potential for contamination and cross-infection between patients.

Choice A rationale:

Glass suctioning catheters are not preferred because they cannot be effectively sterilized for reuse. Reusable materials carry a higher risk of infection transmission and should be avoided when possible.

Choice B rationale:

Metal suctioning catheters are also not the preferred choice for reducing the risk of infection. Like glass catheters, they can be difficult to clean and sterilize adequately for safe reuse. Using disposable materials, like plastic catheters, is a safer option.

Choice C rationale:

While reusable silicone catheters may be more flexible and gentler on the airway, they are not the preferred choice for infection control. Like other reusable materials, they carry a higher risk of contamination and are not as easily disposed of as disposable plastic catheters.

Choice A rationale:

A closed catheter is the most appropriate choice for suctioning a patient with thick secretions. Closed catheters have a two-way valve that allows for continuous suction while minimizing the risk of introducing air into the patient's airway. This design prevents the loss of oxygen and maintains a closed system, reducing the risk of complications such as hypoxia and infection.

Choice B rationale:

Metal catheters are not suitable for suctioning thick secretions. They can be rigid and may cause trauma to the airway, leading to bleeding and discomfort for the patient.

Choice C rationale:

Large French scale catheters are not specifically designed for thick secretions and may not effectively aspirate them. These catheters are typically used for drainage of body cavities or larger organs.

Choice D rationale:

A catheter with a single opening is not ideal for suctioning thick secretions. It may not provide sufficient suctioning power and could lead to ineffective removal of secretions from the patient's airway.

Choice A rationale:

Environmental cleaning before suctioning is crucial to maintain a clean and safe environment for the patient. This reduces the risk of introducing additional contaminants during the procedure.

Choice B rationale:

Using a reusable suctioning catheter is not appropriate for infection control measures. Reusable catheters can harbor microorganisms, even after proper cleaning and sterilization, increasing the risk of cross-contamination.

Choice C rationale:

Proper disposal of used catheters into a regular trash bin is not a suitable infection control measure. Used catheters should be disposed of in designated biohazard containers to prevent exposure to potential pathogens.

Choice D rationale:

Hand hygiene before and after the procedure is essential to reduce the transmission of microorganisms to and from the patient.

Choice E rationale:

Wearing gloves and a mask during suctioning helps protect the nurse from exposure to the patient's bodily fluids and potential infectious agents.

Repeat steps 7 to 9 until no more secretions are obtained or until three passes are completed. Do not suction more than three times in a row to prevent complications. Allow at least one minute of rest between each suction pass to prevent fatigue and distress .

Choice A rationale:

Donning personal protective equipment (PPE) is the priority action before performing sterile suctioning. This helps prevent the transmission of infection from patient to nurse and vice versa.

Choice B rationale:

Preoxygenating the patient with 100% oxygen is essential before nasopharyngeal suctioning, but the priority action is to ensure the nurse's safety by using PPE.

Choice C rationale:

Obtaining baseline data on vital signs and secretions is an important step, but it can be done after the nurse has ensured their safety with appropriate PPE.

Choice D rationale:

Inserting the catheter into the artificial airway using sterile technique is part of the procedure but should be preceded by wearing proper PPE to maintain a sterile environment.

Choice A rationale:

The nurse should not rotate the catheter between the thumb and forefinger during suctioning. This action could cause trauma to the airway.

Choice B rationale:

Limiting each suction pass to no more than 10 seconds is an essential practice during sterile suctioning. Prolonged suctioning can lead to hypoxia and potential complications.

Choice C rationale:

Rinsing the catheter and tubing with saline after each suction pass helps maintain patency and prevent the accumulation of secretions, ensuring effective suctioning during the procedure.

Choice D rationale:

Applying continuous suction while inserting the catheter is not recommended during sterile suctioning. Intermittent suction is preferred for safety and effectiveness.

Choice E rationale:

Providing encouragement and support to the client throughout the procedure is crucial for their comfort and cooperation. Suctioning can be uncomfortable, and the client may need reassurance during the process.

Choice A rationale:

(Incorrect) Stating that it's common for oxygen saturation to drop during suctioning is not appropriate because a drop in oxygen saturation is an abnormal response that requires immediate intervention.

Choice B rationale:

(Incorrect) Telling the patient that a drop in oxygen levels is a normal response and will improve soon is incorrect and may lead to delay in addressing the potential respiratory distress.

Choice C rationale:

(Correct) This response is appropriate because the nurse should stop suctioning immediately if the patient's oxygen saturation drops below the normal range and provide supplemental oxygen to maintain adequate oxygenation.

Choice D rationale:

(Incorrect) Advising the patient to take slow deep breaths to increase oxygen levels may not be sufficient to address the oxygen saturation drop, which requires immediate intervention.

Choice A rationale:

(Incorrect) Assuring the client that the procedure is entirely safe is not entirely accurate, as suctioning can carry some risks and discomfort.

Choice B rationale:

(Correct) This response acknowledges the client's concern about the suctioning procedure while providing a rationale for its importance, which is to maintain clear airways and prevent complications like airway blockage and respiratory distress.

Choice C rationale:

(Incorrect) Stating that there are no other options to remove secretions may not be true, and it does not address the client's concern effectively.

Choice D rationale:

(Incorrect) Promising to suction quickly may not address the client's worry and might compromise the effectiveness of the procedure, as thorough suctioning is necessary.

Choice A rationale:

(Correct) After sterile suctioning, it is essential to reposition the patient to a comfortable and safe position, ensuring proper alignment and support to prevent complications.

Choice B rationale:

(Incorrect) While documentation is crucial, ensuring the patient's safety and comfort should be the immediate priority after the procedure.

Choice C rationale:

(Incorrect) The nurse should not remove the catheter and tubing from the artificial airway immediately after suctioning, as it may still be needed for subsequent interventions.

Choice D rationale:

(Incorrect) Assessing the patient's response to suctioning is essential, but ensuring safety and repositioning take precedence immediately after the procedure.

Choice A rationale:

The nurse should indeed provide reassurance and answer any questions before performing any procedure, as this helps to alleviate the patient's anxiety and ensure they are well-informed about the procedure.

Choice B rationale:

Gathering the necessary equipment and supplies is essential before starting sterile suctioning. This ensures that the nurse has everything needed for the procedure, promoting efficiency and safety.

Choice C rationale:

Connecting the suction tubing to the suction device is an important step in the suctioning process, but it should be done after gathering all the necessary equipment and supplies.

Choice D rationale:

Preoxygenating the patient with 100% oxygen is not a step required before suctioning. Preoxygenation may be necessary before some procedures, but it is not specifically indicated for sterile suctioning.

Choice A rationale:

Continuing suctioning when the patient is experiencing bronchospasm and increased intracranial pressure can worsen their condition and potentially lead to further complications. It is not appropriate to continue suctioning in this situation.

Choice B rationale:

Adjusting the pressure on the suction device may not be sufficient to address the patient's current condition. Stopping suctioning and providing appropriate interventions are more crucial in this situation.

Choice C rationale:

Stopping suctioning immediately is the most appropriate action when the patient experiences bronchospasm and increased intracranial pressure. The nurse should assess the patient's airway, administer bronchodilators or other prescribed treatments as needed, and seek medical assistance if necessary.

Choice D rationale:

Increasing the suction pass time is not recommended as it can exacerbate the patient's condition and lead to complications. The focus should be on stopping suctioning and providing appropriate interventions.

Choice A rationale:

Rinsing the catheter and tubing with saline after each suction pass is not a standard practice and is not necessary for sterile suctioning.

Choice B rationale:

Inserting the catheter into the artificial airway using sterile technique is crucial to maintain the integrity of the procedure and prevent infections.

Choice C rationale:

Limiting each suction pass to no more than 10 seconds helps to prevent complications such as hypoxia and tissue damage.

Choice D rationale:

Providing oral or nasal care after suctioning helps maintain the patient's airway, promote comfort, and prevent infections.

Choice E rationale:

Applying continuous suction while withdrawing the catheter is not recommended as it can cause trauma to the airway and should be avoided during sterile suctioning.

Choice D rationale:

Before performing sterile suctioning on a patient with an endotracheal tube (ETT), the nurse should preoxygenate the patient with 100% oxygen. Suctioning can temporarily decrease oxygen levels in the airway, and preoxygenation helps prevent hypoxia during the procedure.

Choice A rationale:

Checking the patient's blood pressure is not directly related to the preparation for sterile suctioning. However, the nurse should monitor vital signs during and after the procedure.

Choice B rationale:

Placing the patient in the supine position is not a specific requirement for sterile suctioning. The nurse should position the patient appropriately for the procedure to ensure optimal access to the airway.

Choice C rationale:

Inserting the catheter without resistance is not a recommended action. The nurse should assess the patient's airway and ensure proper placement of the suctioning catheter to avoid causing injury or damage.

Choice A rationale:

The nurse should limit each suction pass to no more than 10 seconds to minimize the risk of tissue damage and hypoxia. Prolonged suctioning can cause trauma to the mucosa and lead to inadequate oxygenation.

Choice B rationale:

The nurse should apply suction while inserting the catheter to prevent the catheter from touching the airway walls before suction is initiated. This helps avoid stimulating the gag reflex and causing discomfort to the client.

Choice C rationale:

Rotating the catheter between the thumb and forefinger helps to facilitate even suctioning and prevent the catheter from adhering to the airway walls. It allows for effective removal of secretions without causing harm to the delicate tissues.

Choice D rationale:

After each suction pass, the nurse should rinse the catheter and tubing with saline to maintain its patency and prevent the buildup of secretions. This practice ensures that subsequent suctions are effective in clearing the airway.

Choice E rationale:

Suctioning more than three times in a row is not recommended because it can lead to hypoxia and tissue trauma. Frequent suctioning can reduce the oxygen levels in the airway and cause damage to the delicate tissues.

Choice C rationale:

The nurse should acknowledge the patient's anxiety and respond empathetically. Assuring the patient that the nurse will explain each step during the procedure can help alleviate anxiety. This approach promotes trust and helps the patient feel more in control, which is important for patient cooperation during the suctioning procedure.

Choice A rationale:

Telling the patient not to worry and that it won't take long may come across as dismissive and not address the patient's concerns adequately.

Choice B rationale:

Offering to postpone the procedure is an option, but the nurse should first attempt to address the patient's anxiety and provide reassurance. If the anxiety persists despite the explanation, postponing the procedure can be considered.

Choice D rationale:

Dismissing the patient's anxiety by stating that suctioning is routine may not effectively address the patient's feelings and may not be comforting.

Choice D rationale:

The nurse should respond by acknowledging the discomfort and pausing the procedure to reposition the nasopharyngeal tube. Repositioning can help alleviate the discomfort while ensuring the oxygenation needs are still met.

Choice A rationale:

Increasing the suction pressure may exacerbate the discomfort and cause further irritation to the nose and airway.

Choice B rationale:

Instructing the client to breathe through the mouth may not adequately address the discomfort and may not be feasible if the oxygenation is dependent on the nasopharyngeal tube.

Choice C rationale:

Although explaining the necessity of suctioning is important, it does not directly address the client's immediate discomfort. The priority is to address the client's comfort and safety during the procedure.

Choice A rationale:

The nurse should not discard the used catheter and gloves into a regular trash bin because they were used in a sterile procedure, and improper disposal could lead to the risk of contamination and infection for both the patient and others.

Choice B rationale:

Although it is important to assess the patient's response to suctioning, including vital signs, this should not be the immediate next step after completing sterile suctioning. First, the nurse should ensure their own and the patient's safety by following proper infection control measures.

Choice C rationale:

After completing sterile suctioning, the nurse should perform hand hygiene to prevent the spread of infection and then don a new pair of sterile gloves before performing any other tasks or assessments. This step ensures that the nurse maintains a sterile field and minimizes the risk of introducing pathogens into the patient's airway.

Choice D rationale:

Increasing the suction pressure for one last pass is not necessary and may cause harm to the patient's airway. Proper suctioning technique involves limiting the suctioning time and pressure to avoid tissue damage and potential complications.

Choice A rationale:

Cleaning the inner cannula once a week is insufficient to maintain proper hygiene for a patient with a tracheostomy tube. The inner cannula should be cleaned more frequently, as directed by the healthcare provider, to prevent the accumulation of secretions and potential respiratory complications.

Choice B rationale:

Deflating the cuff before cleaning the tracheostomy tube is not recommended because it may lead to aspiration of secretions or loss of the airway seal. The cuff should only be deflated when it is necessary to remove or change the tracheostomy tube.

Choice C rationale:

Using cotton-tipped applicators to clean the stoma is not the recommended method for tracheostomy care. Sterile tracheostomy care kits usually include specialized brushes or swabs designed for this purpose, ensuring effective and safe cleaning of the stoma without the risk of shedding fibers or causing injury.

Choice D rationale:

Changing the tracheostomy ties every 24 hours is the appropriate action. Regular changing of the ties helps prevent complications such as skin breakdown, ensures a secure fit of the tracheostomy tube, and reduces the risk of infection.

Choice A rationale:

Limiting the suctioning time to 15 seconds may still be too long for some patients, increasing the risk of hypoxia and other complications related to prolonged suctioning. The optimal suctioning time should be shorter to minimize adverse effects.

Choice B rationale:

Limiting the suctioning time to 20 seconds is longer than the recommended duration. Prolonged suctioning can cause hypoxia, increased intracranial pressure, and other adverse effects, making it crucial to keep the time as short as possible.

Choice C rationale:

Suctioning time should generally be limited to 10 seconds to reduce the risk of complications while effectively clearing the patient's airway. This duration allows for adequate removal of secretions without causing significant disturbances to the patient's oxygenation and hemodynamic stability.

Choice D rationale:

Limiting the suctioning time to 5 seconds is too short to effectively clear secretions from the airway, especially in patients with excessive or tenacious secretions. Sufficient time is needed to ensure proper removal of respiratory secretions and maintain the patient's airway patency.

Choice A rationale:

The nurse should not insert the catheter until resistance is met during nasopharyngeal suctioning. This action could cause trauma to the nasal mucosa or other structures in the nasopharynx.

Choice B rationale:

Preoxygenating the patient with 100% oxygen is important before nasopharyngeal suctioning to prevent hypoxia during the procedure. Suctioning can temporarily decrease oxygen levels, so preoxygenation helps maintain adequate oxygenation.

Choice C rationale:

Applying intermittent suction while inserting the catheter is not recommended during nasopharyngeal suctioning. Continuous suction is preferred for effective removal of secretions.

Choice D rationale:

Limiting each suction pass to no more than 15 seconds is an essential practice during nasopharyngeal suctioning. Prolonged suctioning can cause hypoxia and discomfort for the patient.

Choice E rationale:

Rinsing the catheter and tubing with saline after each suction pass helps maintain patency and prevent the accumulation of secretions, ensuring effective suctioning during the procedure.

Choice A rationale:

A cuffed tracheostomy tube is most suitable for a patient who requires mechanical ventilation or has a high risk of aspiration. The cuff is inflated to create a seal between the trachea and the tube, preventing aspiration of oral secretions or gastric contents into the airway. This is crucial for patients on mechanical ventilation to ensure effective ventilation and prevent complications like ventilator-associated pneumonia.

Choice B rationale:

Uncuffed tracheostomy tubes do not have an inflatable cuff, making them unsuitable for patients who require mechanical ventilation or have a high risk of aspiration. They are more appropriate for patients who can protect their own airway and have minimal risk of aspiration.

Choice C rationale:

Fenestrated tracheostomy tubes have an opening or fenestration on the tube that allows airflow through the upper airway, bypassing the tracheostomy tube. These tubes are used for patients who are weaning off mechanical ventilation and require speech therapy. They are not the most suitable choice for patients who need mechanical ventilation or have a high aspiration risk.

Choice D rationale:

Double-lumen tracheostomy tubes have two separate tubes, which can be used for independent lung ventilation in certain situations. They are not specifically designed for patients requiring mechanical ventilation or with a high risk of aspiration.

Choice E rationale:

Metal tracheostomy tubes are not commonly used for patients requiring mechanical ventilation or with a high risk of aspiration. Metal tubes may be used in certain cases, but they are not the most suitable choice for this patient population.

Choice C rationale:

A fenestrated tracheostomy tube would be the most appropriate choice for a client who is ready to wean from mechanical ventilation and also requires speech therapy. The fenestration in the tube allows the patient to breathe through the upper airway, facilitating the weaning process, and enabling speech by allowing air to pass over the vocal cords. This type of tube is commonly used for patients who have progressed in their recovery and are transitioning to breathing independently.

Choice A rationale:

A cuffed tracheostomy tube with an inflated cuff is more suitable for patients requiring mechanical ventilation or those at high risk of aspiration, rather than a patient who is ready to wean from ventilation.

Choice B rationale:

Uncuffed tracheostomy tubes may be appropriate for patients who can protect their airway and are weaning from mechanical ventilation. However, they would not be the most appropriate choice when speech therapy is also required.

Choice D rationale:

Double-lumen tracheostomy tubes are not typically used for weaning from mechanical ventilation or speech therapy needs. They are employed in specialized situations for independent lung ventilation.

Choice E rationale:

Plastic tracheostomy tubes are commonly used in clinical practice and may be suitable for a patient ready to wean from mechanical ventilation and requiring speech therapy. However, the fenestrated tube is a more specific choice for this scenario.

Choice D rationale:

This statement is correct. A fenestrated tracheostomy tube is designed for patients with a low risk of aspiration and are weaning from mechanical ventilation. The fenestration allows the patient to breathe through the upper airway, promoting speech and facilitating the weaning process. The fenestration can be temporarily occluded to assess the patient's readiness for decannulation.

Choice A rationale:

Monitoring cuff pressure is essential, but the suggested range of 20 to 25 cm H2O is not universally applicable. The appropriate cuff pressure range may vary depending on the patient's condition, and it should be individualized based on the patient's needs.

Choice B rationale:

Keeping the fenestration open at all times is not accurate. The fenestration can be open to allow airflow during weaning and speech therapy, but it can be temporarily occluded when assessing the patient's ability to breathe without the tube.

Choice C rationale:

The inner cannula is not solely used during mechanical ventilation. It is also used for routine cleaning and maintenance of the tracheostomy tube, regardless of the patient's ventilation status.

Choice E rationale:

Metal tracheostomy tubes are not commonly used for long-term ventilation. They are mostly used in specific situations where a plastic tube may not be suitable, such as when there is a risk of tube distortion or damage. Plastic tubes are more commonly used for long-term ventilation due to their availability, flexibility, and ease of use.

Choice A rationale:

A cuffed tracheostomy tube has an inflatable cuff that can create a seal in the trachea, but it also increases the risk of aspiration. In this case, the patient is at low risk of aspiration, so a cuffed tube is not the most suitable choice.

Choice B rationale:

An uncuffed tracheostomy tube lacks an inflatable cuff, which reduces the risk of aspiration. It allows air to flow freely around the tube and is appropriate for patients with a low risk of aspiration, making it the most suitable choice for this patient.

Choice C rationale:

A fenestrated tracheostomy tube has an opening in the posterior wall that allows airflow through the vocal cords, facilitating speech. However, since the patient is already speaking with a low risk of aspiration, a fenestrated tube may not be necessary or the best choice.

Choice D rationale:

A double-lumen tracheostomy tube is designed for independent lung ventilation during certain medical procedures and is not typically used for routine tracheostomy management. It would not be the most suitable choice in this scenario.

Choice E rationale:

Silicone tracheostomy tubes are made of a soft, flexible material that can reduce the risk of tissue damage and provide greater comfort. However, the material of the tracheostomy tube is not the primary consideration for a patient with a low risk of aspiration.

Choice A rationale:

Performing tracheostomy care every 2 to 4 hours would be too frequent for most patients and may cause unnecessary disruption and discomfort. This interval is not the recommended standard of care.

Choice B rationale:

Tracheostomy care every 4 to 6 hours strikes a balance between maintaining airway hygiene and minimizing excessive handling of the tracheostomy site, reducing the risk of complications such as infection or irritation.

Choice C rationale:

Waiting to perform tracheostomy care every 6 to 8 hours may increase the risk of mucus buildup and potential complications, especially in patients with high secretions or respiratory issues.

Choice D rationale:

Extending the interval to every 8 to 12 hours may lead to inadequate airway clearance and increased risk of complications in patients who require more frequent care.

Choice E rationale:

Waiting to perform tracheostomy care every 12 to 24 hours is too infrequent for most patients and may not be sufficient to maintain a patent airway and prevent complications.

Choice A rationale:

Administering antibiotics would be indicated if the patient develops a respiratory infection, but it would not directly address the issue of dry and crusted secretions.

Choice B rationale:

Increasing suction frequency may help remove secretions, but it may also lead to increased irritation and trauma to the tracheal lining. It is not the first-line intervention for dry and crusted secretions.

Choice C rationale:

Providing humidification and hydration helps to moisten the secretions, making them easier to expectorate or suction. It is the most appropriate intervention to address dry and crusted secretions in a patient with a tracheostomy tube.

Choice D rationale:

Performing daily tracheostomy tube changes is not indicated solely to address dry and crusted secretions unless there is a specific problem with the current tube that requires changing.

Choice E rationale:

Recommending a fenestrated tracheostomy tube would not directly address the issue of dry and crusted secretions. Fenestrated tubes are more relevant for patients who need speech assistance, which is not the primary concern in this case.

Choice A rationale:

Positioning the patient in semi-Fowler's position (Choice A) is an important step in tracheostomy care, but it is not the first step during the suctioning procedure. Semi-Fowler's position helps promote lung expansion and allows for better visualization during the procedure.

Choice B rationale:

Applying a new dressing around the stoma (Choice B) is essential after suctioning to maintain cleanliness and prevent infection. However, it is not the first step in the suctioning procedure. The nurse should first gather the necessary equipment.

Choice C rationale:

Cleaning the inner cannula with hydrogen peroxide (Choice C) is not the first step during suctioning. The nurse should gather equipment and supplies first before performing any cleaning or other procedures.

Choice E rationale:

Removing the old dressing and discarding it in a moisture-resistant bag (Choice E) is an important step, but it should come after the nurse gathers the necessary equipment for the suctioning procedure.

Choice A rationale:

Cleaning the stoma with hydrogen peroxide (Choice A) is not recommended for tracheostomy care. Hydrogen peroxide can be irritating and damaging to the tissues. Normal saline solution should be used to clean the stoma.

Choice B rationale:

Changing the ties or straps every 4 hours (Choice B) is not necessary unless they are soiled or loose. Frequent changes may irritate the skin and increase the risk of infection. Straps should be changed only when needed.

Choice C rationale:

Inspecting the stoma for signs of infection (Choice C) is a crucial step in tracheostomy care. Signs of infection may include redness, swelling, discharge, or foul odor. Prompt identification and treatment of infection are essential to prevent complications.

Choice E rationale:

Applying a new dressing around the stoma and securing it with tape (Choice E) is essential after tracheostomy care to maintain cleanliness and protect the stoma. Proper dressing helps prevent infection and skin breakdown.

Suctioning a tracheostomy tube is a sterile, invasive technique that requires a nurse or a respiratory therapist. It is done to remove secretions from the tube and prevent obstruction, infection, or hypoxia. The steps of suctioning a tracheostomy tube are:

Choice A rationale:

Placing the patient in a prone position (Choice A) would not be suitable for suctioning a tracheostomy tube as it may impede breathing and proper access to the tracheostomy site.

Choice B rationale:

Placing the patient in a supine position (Choice B) is not the optimal position for tracheostomy suctioning. Semi-Fowler's position is preferred as it allows better lung expansion and facilitates the suctioning procedure.

Choice D rationale:

Placing the patient in Trendelenburg position (Choice D) is not appropriate for tracheostomy suctioning. Trendelenburg position is typically used for certain cardiovascular conditions and not for tracheostomy care.

Choice A rationale:

Sterile gloves are essential for aseptic technique during tracheostomy suctioning to prevent the introduction of infection. However, they are not included in the setup, as they are worn by the nurse performing the procedure.

Choice B rationale:

Sterile water or saline is necessary for suctioning to moisten the suction catheter and facilitate the removal of secretions without causing trauma to the airway. Therefore, it should be included in the setup.

Choice C rationale:

A pulse oximeter is used to monitor the patient's oxygen saturation and is not directly related to tracheostomy suctioning. While continuous monitoring of oxygen saturation is essential during and after the procedure, it is not a part of the setup.

Choice D rationale:

A sphygmomanometer is used to measure blood pressure and is unrelated to tracheostomy suctioning. It is not required for this procedure.

Choice E rationale:

A non-sterile towel is used to protect the patient's clothing and bed linens from any secretions or spills during the suctioning procedure. It should be included in the setup to maintain cleanliness and prevent contamination.

Choice A rationale:

This response is dismissive of the patient's feelings and may increase their anxiety. It does not address the patient's concern appropriately.

Choice B rationale:

This response acknowledges the patient's anxiety and provides a clear explanation for the necessity of the procedure. It is empathetic and supportive while also emphasizing the importance of the intervention.

Choice C rationale:

This response is not entirely reassuring and may not be accurate. Simply asking the patient to trust the nurse without explaining the procedure further may not alleviate the patient's anxiety.

Choice D rationale:

Skipping the procedure without a valid reason may compromise the patient's airway and respiratory function. Postponing essential procedures is not appropriate unless there are specific clinical reasons for doing so.

Choice A rationale:

This response acknowledges the patient's concern and provides a realistic expectation of potential discomfort during the procedure. It offers reassurance that any pain experienced will be brief.

Choice B rationale:

This response is not entirely accurate. While the procedure itself may not cause pain, some patients may experience discomfort during tracheostomy suctioning due to the sensation of suction in the airway.

Choice C rationale:

This response is not appropriate as it exaggerates the potential pain, causing unnecessary distress to the patient.

Choice D rationale:

Administering pain medication solely for the discomfort associated with tracheostomy suctioning is not standard practice. Pain medication should only be given for clinically significant pain or as part of a larger pain management plan.