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 D
Explanation
A. "You may drink full liquids until 6 hours before the procedure": Typically, clients are instructed to follow a clear liquid diet and to stop drinking any liquids a few hours before the procedure, not full liquids.
B. "You will lie on your right side for the procedure": The client usually lies on their left side during a colonoscopy, not the right side.
C. "You should warm the liquid bowel preparation before drinking it": Bowel preparation solutions are generally not warmed; they are consumed as directed, often chilled to make them more palatable.
D. "You will be moderately sedated during the procedure": This is correct as colonoscopy usually involves moderate sedation to ensure client comfort and tolerance during the procedure.
Correct Answer is D
Explanation
A. Have the client drink contrast medium: This is incorrect as contrast medium is typically not required for an esophagogastroduodenoscopy (EGD); it is used for other types of imaging studies.
B. Shave the client from axillae to groin: This is incorrect; shaving is not necessary for an EGD procedure.
C. Administer a cleansing enema: This is incorrect as an enema is generally not required for an EGD, which focuses on the upper gastrointestinal tract.
D. Ensure the signed consent is in the medical record: This is correct as ensuring that the consent form is signed and documented is crucial for legal and procedural reasons before performing an EGD.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.