A nurse is caring for a client who has a tracheostomy.
Which of the following actions should the nurse perform first when providing tracheostomy care?
Change the dressing on the tracheostomy site.
Suction the tracheostomy tube.
Auscultate the client’s lungs.
Clean the inner cannula.
The Correct Answer is C
A. Changing the dressing on the tracheostomy site is an important part of tracheostomy care, but it is not the first action that should be taken.
B. Suctioning the tracheostomy tube should only be performed if there are signs of airway obstruction (e.g., increased secretions, decreased oxygenation, or adventitious breath sounds). Suctioning too frequently or unnecessarily can cause mucosal damage and hypoxia.
C. Auscultating the lungs helps the nurse determine if there is increased secretions, diminished breath sounds, or other airway concerns that may require suctioning. This ensures that care is performed appropriately based on the client’s needs.
D. Cleaning the inner cannula is a necessary part of tracheostomy care, but it should be done after assessing the airway and performing suctioning if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Wearing a surgical mask when entering the patient’s room is a standard precaution for all healthcare workers, but it may not be sufficient for a patient with severe coughing, night sweats, and blood in the sputum. These symptoms could indicate a contagious disease such as tuberculosis, which requires airborne precautions.
Choice B rationale
Placing the patient in a negative-pressure airflow room is the correct action. This type of room is used for patients who may have airborne infectious diseases. The negative pressure prevents airborne pathogens from escaping the room and infecting others.
Choice C rationale
Keeping a container for soiled linens outside the patient’s door is not the most appropriate action in this situation. While it is important to handle soiled linens properly to prevent the spread of infection, it does not address the potential airborne transmission of pathogens.
Choice D rationale
Remaining within 3 feet of the patient is not the most appropriate action in this situation. If the patient has an airborne infectious disease, healthcare workers should minimize close contact to prevent exposure.
Correct Answer is B
Explanation
Choice A rationale
Limiting physical activity until bladder continence is achieved is not typically part of a bladder training program. Physical activity can actually help improve bladder control by strengthening the pelvic floor muscles.
Choice B rationale
Instructing the client to void at scheduled times throughout the day is a key component of bladder training. This helps retrain the bladder to hold urine for longer periods and reduces episodes of incontinence.
Choice C rationale
Instructing the client to void as soon as they feel the urge is not typically part of a bladder training program. The goal of bladder training is to gradually extend the time between voids.
Choice D rationale
Encouraging the client to contract the abdominal muscles when they experience the urge to void is not typically part of a bladder training program. This could potentially lead to more leakage.
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