Which action would the nurse include when performing tracheostomy care on a client receiving mechanical ventilation?

ANS: C

Rationale:
Pleurisy is caused by inflammation of the pleural surfaces, and a frequent clinical manifestation is a pleural friction rub, which is a rough, scratching, grating, creaking sound caused by inflamed pleural surfaces rubbing together. It is frequently associated with chest pain.

A- Stridor is a high-pitched, shrill, harsh sound caused by laryngeal obstruction and can be heard on auscultation over the upper airways or with the naked ear.

B- Rhonchi are continuous, low-pitched, coarse sounds often described as having a snoring or moaning quality that occur with partial bronchial obstruction caused by mucus, bronchospasm, foreign bodies, or tumors.

D- High pitched crackles are fine, short, interrupted popping sounds best heard on inspiration that occur with problems such as heart failure when air passes through fluid within the alveoli.

ANS: C

Rationale:
The client's statement indicates readiness to develop a plan to regain speech, and the speech therapist's role is to assess the client, then develop and implement a plan to regain speech.

A- The statement, "Every client with a laryngectomy is different. It's difficult to say," is an evasive answer and offers no plans for goal setting.

B- Initially, the response, "It must be difficult for you, but be patient. These things take time," identifies feelings, but does not answer the client's question.

D- Written information can be helpful, but the nurse does not know whether esophageal speech is a good option for this client.

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