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 C
Explanation
Choice A rationale
Storing extra blankets in a box on the steps is not a safe practice for a client who has just returned home after a total hip arthroplasty. This could increase the risk of falls, which is a major concern after hip surgery.
Choice B rationale
Keeping pot handles turned towards the edge of the stove is not a safe practice. It increases the risk of spills and burns. Pot handles should always be turned towards the back of the stove to prevent accidents.
Choice C rationale
Placing electrical cords against the wall is a safe practice. It reduces the risk of tripping over the cords, which is especially important for a client who is recovering from a total hip arthroplasty.
Choice D rationale
Placing a throw rug next to the bathtub is not a safe practice. Throw rugs can easily slip and cause falls. A non-slip mat should be used instead.
Correct Answer is C
Explanation
Choice A rationale
Rolling down knee-high stockings can cause constriction and impair blood flow, which is not the intended purpose of these stockings.
Choice B rationale
Flexing the toes when applying the stockings does not necessarily aid in the application or effectiveness of the stockings.
Choice C rationale
Antiembolic stockings should be reapplied before getting out of bed to ensure that they are in place to provide the necessary pressure to the legs when the client is upright. This helps to promote venous return and prevent blood pooling and clot formation.
Choice D rationale
Thigh-high stockings should reach just below the gluteal folds, not above. If they are too high, they can cause constriction and impair blood flow.
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