NCLEX Examination.
Practice Question # 814.
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1. Question
The nurse is caring for a client after a laryngectomy. The client is anxious, with a respiratory rate of 32 and an oxygen saturation of 88. The nurse’s first action should be to:
Correct
Answer A is correct.
Rationale: Obstruction of the tracheostomy can cause anxiety, increased respiratory rate, and an O2 saturation decrease. The nurse should first suction the client. If this doesn’t work, she should notify the physician, as in answer C. Answer B would not help if the tube was obstructed. Answer D would be done to assess for improvement after the suctioning was performed.
Incorrect
Answer A is correct.
Rationale: Obstruction of the tracheostomy can cause anxiety, increased respiratory rate, and an O2 saturation decrease. The nurse should first suction the client. If this doesn’t work, she should notify the physician, as in answer C. Answer B would not help if the tube was obstructed. Answer D would be done to assess for improvement after the suctioning was performed.
