A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first?

Transfer the client to the emergency department.

Call for the registered nurse to reinsert the tube.

Cover the tracheostomy site with a sterile gauze to prevent infection.

Place a dilator in the stoma to maintain the opening.

Answer and Explanation

The Correct Answer is D

A. Transfer the client to the emergency department: Transferring the client delays immediate airway management, which is critical. This action is not appropriate as the first step because airway patency must be addressed on the spot to prevent respiratory distress.
B. Call for the registered nurse to reinsert the tube: While notifying the RN is important, maintaining the airway takes precedence. Waiting for another provider before taking action risks closure of the stoma and airway compromise.
C. Cover the tracheostomy site with a sterile gauze to prevent infection: Covering the site without maintaining patency could cause the stoma to close rapidly. Infection control is important, but it is secondary to preserving the airway.
D. Place a dilator in the stoma to maintain the opening: Inserting a tracheostomy dilator prevents the stoma from closing and buys time for reinsertion of the tube. This is the immediate priority to ensure the airway remains open and the client can breathe effectively.

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Correct Answer is A

Explanation

A. Dextromethorphan: Dextromethorphan is an antitussive commonly used to suppress non-productive coughs. It acts on the cough center in the medulla to reduce the frequency and intensity of coughing, making it ideal for nighttime relief.
B. Pseudoephedrine: Pseudoephedrine is a decongestant that reduces nasal congestion by vasoconstriction. It does not suppress cough and can actually cause insomnia due to its stimulant effects, making it inappropriate for nighttime use.
C. Diphenhydramine: Diphenhydramine is an antihistamine that may have mild cough suppressant properties and cause sedation. Its primary action is to block histamine receptors, which is more useful for allergic reactions and related symptoms like runny nose or itching. It's not a direct cough suppressant.
D. Fluticasone: Fluticasone is a corticosteroid typically used as a nasal spray for allergic rhinitis. It is not effective for acute cough relief and has no role in suppressing a dry, nighttime cough.

A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis

Correct Answer is C

Explanation

A. Metabolic alkalosis: This condition results from excess bicarbonate or loss of acids through vomiting or diuretics. It is not associated with rapid, shallow breathing, especially in the early phase of heart failure.
B. Metabolic acidosis: Typically seen in states of increased acid production or bicarbonate loss, such as in renal failure or diarrhea. It is not the expected initial response to hyperventilation caused by early heart failure.
C. Respiratory alkalosis: Rapid, shallow breathing (tachypnea) leads to excessive exhalation of CO₂, resulting in decreased carbonic acid and increased blood pH. This is the typical early blood gas finding in acute heart failure due to hypoxia-driven hyperventilation.
D. Respiratory acidosis: This occurs when CO₂ is retained due to hypoventilation. Since the client is hyperventilating rather than hypoventilating, respiratory acidosis would not be present initially.

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A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first?

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Correct Answer is A

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