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.
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Related Questions
Correct Answer is B
Explanation
A. Apply a heat pack to the client's lower abdomen: This is incorrect as applying heat can worsen inflammation and increase the risk of rupture; ice packs are generally used instead.
B. Place the client in semi-Fowler's position: This is correct as the semi-Fowler's position helps reduce pain and pressure on the abdomen and can improve comfort before surgery.
C. Give the client a clear liquid diet: This is incorrect as a clear liquid diet is not appropriate for a client with acute appendicitis who may require NPO (nothing by mouth) status prior to surgery.
D. Administer an enema to the client: This is incorrect as enemas are contraindicated in acute appendicitis due to the risk of perforation and worsening of the condition.
Correct Answer is B
Explanation
A. Suggest fresh fruits and vegetables: This is incorrect because clients with HIV, especially those with immunosuppression, might be at increased risk for foodborne illnesses from fresh produce. Proper food handling and possibly cooked vegetables might be recommended instead.
B. Offer small, frequent meals: This is correct because small, frequent meals can help manage symptoms like nausea or loss of appetite, which are common in clients with HIV.
C. Provide a diet of pureed foods: This is unnecessary unless the client has specific swallowing difficulties. Generally, pureed foods are not required unless indicated by the client's condition.
D. Encourage fluids with meals: This is incorrect as consuming large amounts of fluids with meals may lead to early satiety, which is not ideal for clients needing to maintain or gain weight.
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