ATI PN Adult Med Surg 2020 with NGN
ATI PN Adult Med Surg 2020 with NGN ( 101 Questions)
A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?
The correct answer is choice A, Perform suctioning. Restlessness and crackles in the lungs may indicate respiratory distress or airway obstruction, which may be due to mucus or secretions blocking the tracheostomy tube. Performing suctioning helps clear the airway of secretions, which will improve the client's breathing. Choice B is incorrect because instilling saline into the tubing is not a common intervention for managing restlessness and crackles. Choice C is incorrect because checking the cuff pressure is not related to managing restlessness and crackles. Choice D is incorrect because increasing humidification is not a common intervention for managing restlessness and crackles.
Other choices:
Instill saline into the tubing: Instilling saline into the tubing is not a common intervention for managing restlessness and crackles.
Check the cuff pressure: Checking the cuff pressure is not related to managing restlessness and crackles.
Increase the humidification: Increasing humidification is not a common intervention for managing restlessness and crackles.
The correct answer is choice A, Perform suctioning. Restlessness and crackles in the lungs may indicate respiratory distress or airway obstruction, which may be due to mucus or secretions blocking the tracheostomy tube. Performing suctioning helps clear the airway of secretions, which will improve the client's breathing. Choice B is incorrect because instilling saline into the tubing is not a common intervention for managing restlessness and crackles. Choice C is incorrect because checking the cuff pressure is not related to managing restlessness and crackles. Choice D is incorrect because increasing humidification is not a common intervention for managing restlessness and crackles.
Other choices:
Instill saline into the tubing: Instilling saline into the tubing is not a common intervention for managing restlessness and crackles.
Check the cuff pressure: Checking the cuff pressure is not related to managing restlessness and crackles.
Increase the humidification: Increasing humidification is not a common intervention for managing restlessness and crackles.