A nurse is caring for a client who has a tracheostomy. When providing tracheostomy care, which of the following actions should the nurse perform first?
Change the dressing on the tracheostomy site.
Suction the tracheostomy tube.
Auscultate the client's lungs.
Clean the inner cannula.
The Correct Answer is B
A. Change the dressing on the tracheostomy site: Although changing the dressing is an important part of tracheostomy care, it should be performed after ensuring that the airway is patent and clear. The priority is to maintain an open airway and prevent obstruction.
B. Suction the tracheostomy tube: Suctioning the tracheostomy tube should be performed first to clear any secretions or obstructions that could impair breathing. Ensuring the airway is clear is critical before proceeding with other care tasks.
C. Auscultate the client's lungs: While auscultation is important for assessing lung sounds and the overall respiratory status, it is secondary to ensuring the tracheostomy tube is clear. The priority is to address any potential airway obstructions first.
D. Clean the inner cannula: Cleaning the inner cannula is an essential part of tracheostomy care, but it should be done after ensuring the airway is clear and patent. Prioritizing suctioning ensures that the cannula can be cleaned effectively without interference from secretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will have hot, dry, and flushed skin if I am having a heart attack": This statement is incorrect as it does not accurately reflect typical symptoms of a heart attack. Common symptoms include chest pain, shortness of breath, and possibly cold sweat, not hot, dry, and flushed skin.
B. "I will wait 30 minutes before taking action if I have heartburn": Waiting 30 minutes before taking action is incorrect for angina or heartburn. Immediate action is required for angina symptoms, and heartburn should be differentiated from angina by a healthcare provider.
C. "I will notify emergency response if I have sudden jaw pain": This statement is correct because sudden jaw pain can be a symptom of angina or a heart attack, indicating that immediate medical attention is needed.
D. "I will take four nitroglycerin sublingual tablets if I have chest pain": This statement is incorrect as taking four nitroglycerin tablets is excessive and could be harmful. The standard recommendation is to take one tablet every 5 minutes for up to three doses if chest pain persists, and then seek medical attention.
Correct Answer is B
Explanation
A. Eat lighter, low-calorie foods first: While light foods can be easier to consume, prioritizing low-calorie foods may not address the client's nutritional needs. The focus should be on high-calorie, high-protein foods to maintain weight and strength.
B. Limit fluid intake during meals: This is correct as limiting fluid intake during meals can help prevent bloating and early satiety, which can be an issue for clients with COPD who have reduced appetite.
C. Eliminate dairy products: There is no general indication to eliminate dairy products unless the client has a specific intolerance or allergy. Dairy products are not universally problematic for clients with COPD.
D. Consume three regular meals daily: Clients with COPD may benefit from smaller, more frequent meals rather than three large meals to prevent feelings of fullness that can reduce appetite and increase shortness of breath.
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