The nurse has placed an oropharyngeal airway in a client. What ...

[brutforce]

The nurse has placed an oropharyngeal airway in a client. What action should the nurse take at this time?
 
  1. Tape the airway in place.
  2. Suction the client.
  3. Turn the client's head to the side.
  4. Insert a nasal trumpet.

Question 2

The nurse who is assessing a client's chest tube insertion site notices a fine crackling sound and feeling upon palpating the area. What action should the nurse take?
 
  1. Discontinue the chest tube suction.
  2. Collaborate with the client's physician.
  3. Mark the area involved and remove the tube.
  4. Reinforce the chest tube dressing.

[voltaire123]

Answer to Question 1

Correct Answer: 3
Rationale 1: The airway should not be taped in place as it would then act as an airway obstruction if dislodged.
Rationale 2: While suctioning the client is possible with the airway in place, the client should be suctioned only when it is necessary.
Rationale 3: The nurse should turn the client's head to the side to allow drainage of oral secretions.
Rationale 4: Insertion of a nasal trumpet or nasopharyngeal airway is not necessary when the oropharyngeal airway is in place.

Answer to Question 2

Correct Answer: 2
Rationale 1: Chest tube suction should not be discontinued.
Rationale 2: The nurse should collaborate with the client's physician regarding this finding.
Rationale 3: The tube should not be removed.
Rationale 4: Simply reinforcing the chest tube dressing will not prevent further air loss and does not allow for physician input.