a client has a tracheostomy tube in place when the nurse suctions the client food particles are noted what action by the nurse is best
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?

Correct answer: B

Rationale: When food particles are noted during suctioning of a client with a tracheostomy tube, it can indicate tracheomalacia due to constant pressure from the tracheostomy cuff. This condition may lead to dilation of the tracheal passage. To address this issue, the nurse should measure and compare cuff pressures. By monitoring these pressures and comparing them to previous readings, the nurse can identify trends and potential complications. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not directly address the cuff pressure issue causing food particles in the secretions.

2. A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?

Correct answer: D

Rationale: Seizure activity lasting longer than 5 minutes requires immediate intervention as it can lead to status epilepticus, a medical emergency.

3. A client is moving to a new state and needs to find a new doctor and hospital there. What advice by the nurse is best?

Correct answer: C

Rationale: Choosing a hospital accredited by The Joint Commission (TJC) or another accrediting body is the best advice as it ensures a focus on safety and quality standards.

4. A client who will undergo a bronchoscopy procedure with a rigid scope and general anesthesia will have their neck in which of the following positions?

Correct answer: D

Rationale: During a bronchoscopy with a rigid scope and general anesthesia, the provider will typically place the client's neck in a hyperextended position to allow better visualization and access to the airways. This position helps to align the trachea for easier insertion of the scope.

5. A client with emphysema is being cared for by a nurse. Which of the following findings should the nurse not expect to assess in this client?

Correct answer: B

Rationale: Emphysema is a chronic lung condition characterized by shortness of breath (dyspnea), a barrel-shaped chest due to hyperinflation of the lungs (barrel chest), and clubbing of the fingers (enlargement of fingertips). Bradycardia (slow heart rate) is not typically associated with emphysema. In emphysema, the primary focus is on respiratory complications rather than cardiac issues.

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