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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "I should use my wrist to test the temperature of the water before bathing": This is correct as using the wrist to test water temperature helps prevent burns or injuries, which is crucial for individuals with diabetes who may have reduced sensation in their feet.
B. "I should put lotion between my toes every day to prevent dryness and cracking": This is incorrect because applying lotion between the toes can promote fungal infections. Lotion should be applied to the tops and soles of the feet, avoiding the spaces between the toes.
C. "I should apply a heating pad to my feet every night to help with circulation": This is incorrect as heating pads can cause burns due to decreased sensation. It is safer to avoid direct heat applications.
D. "I should round the corners of my toenails with a nail file to prevent ingrown nails": This is incorrect; toenails should be trimmed straight across to prevent ingrown nails rather than rounded.

A. Place the client in a negative-pressure airflow room. B. Wear a surgical mask when entering the client's room. C. Have a container for soiled linens outside the client's door. D. Remain within 91.4 cm (3 ft) of the client.

Correct Answer is A

Explanation

A. Place the client in a negative-pressure airflow room: This is correct as these symptoms are indicative of tuberculosis (TB), which requires airborne precautions. A negative-pressure room helps to prevent the spread of airborne pathogens.
B. Wear a surgical mask when entering the client's room: This is incorrect because a surgical mask does not provide adequate protection against airborne particles; an N95 respirator is necessary for airborne precautions.
C. Have a container for soiled linens outside the client's door: This is incorrect as soiled linens should be handled and disposed of within the room under appropriate infection control protocols, not just placed outside.
D. Remain within 91.4 cm (3 ft) of the client: This is incorrect as maintaining this distance does not prevent the spread of airborne diseases. Proper airborne precautions, including the use of personal protective equipment, are necessary.

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