Ms. Marlyn, R.N., is assigned to Mr. Loi, a post thyroidectomy patient.
41. Assessing her condition, the physician ordered Stat tracheostomy. The clinical parameters for doing so are the following, except:
A. Hypoventilation
B. Hypertension
C. Fatigue
D. Ineffective cough due to body weakness
42. Which of these is not the nursing management following tracheostomy?
A. Prevent infection
B. Maintain patent airway every two hours only
C. Provide proper humidification
D. Avoid misalignment by securing tracheostomy tube with clean cloth tape
43. The following are the nursing intervention to be observed after tracheostomy care:
A. Evaluate mucous membrane color
B. Monitor for level of consciousness
C. Observe indication of shock
D. Monitor vital signs every 30 minutes
44. This is an intervention for tracheostomy care:
A. Put on sterile gloves always
B. Wash hands and clean under fingernails
C. Soak the trochanter tube with sterile water
D. Never position knots directly over the spinal cord or the carotid artery if trachostomy tie is being changed
45. The solution to be instilled into the trachea if tracheal secretions are thick is:
A. Potassium permanganate
B. Dextrose 10% NSS
C. Sterile normal saline
D. Sterile water
