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 B

Explanation

A. Shift of rib cage toward affected side: The rib cage does not typically shift in tension pneumothorax. Instead, the thorax on the affected side may appear hyperinflated or fixed in inspiration but does not physically shift toward the affected side.
B. Shift of trachea, esophagus, heart, and great vessels: A tension pneumothorax can cause increased intrathoracic pressure, pushing the mediastinal structures toward the unaffected side. This mediastinal shift is a critical sign and can lead to impaired cardiac output and respiratory collapse.
C. Fluctuation of the fluid in the water-seal chamber: This is an expected finding in a chest tube system and indicates proper function. It does not reflect a mediastinal shift and is not specific to tension pneumothorax.
D. Sucking sound heard on inspiration and expiration: This is more commonly associated with an open pneumothorax, not a tension pneumothorax. Tension pneumothorax involves air trapping without an external opening.

A. The client should have a bowel movement every day to avoid development of an intestinal obstruction. B. The client can develop a rectal fissure, which will increase pain levels. C. The client should not develop hemorrhoids. D. Straining engages the Valsalva maneuver, which can cause dangerous effects.

Correct Answer is D

Explanation

A. The client should have a bowel movement every day to avoid development of an intestinal obstruction: While regular bowel movements are important, going two days without one is not uncommon and does not usually lead to obstruction. The priority in heart failure is avoiding strain, not frequency alone.
B. The client can develop a rectal fissure, which will increase pain levels: Although rectal fissures can occur with hard stools, they are not the primary concern in a heart failure patient. The hemodynamic effects of straining pose a greater immediate risk.
C. The client should not develop hemorrhoids: Preventing hemorrhoids is beneficial but not critical in the context of heart failure. The concern with straining extends beyond local complications like hemorrhoids to systemic cardiovascular effects.
D. Straining engages the Valsalva maneuver, which can cause dangerous effects: The Valsalva maneuver increases intrathoracic pressure, reducing venous return and cardiac output. In clients with heart failure, this can trigger arrhythmias, syncope, or even cardiac decompensation, making stool softeners essential for prevention.

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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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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with tension pneumothorax. Which nursing assessment would alert the nurse to the development of a mediastinal shift in this client?

Correct Answer is B

Explanation

A client with heart failure reports not having had a bowel movement in 2 days. Why would it be important for the nurse to obtain a prescription for a stool softener?

Correct Answer is D

Explanation

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