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 A
Explanation
Choice A rationale
Limiting sodium intake to no more than 2,000 milligrams per day is a recommended strategy to prevent hypertension. Excessive sodium intake can increase blood pressure by causing the body to retain fluid, which increases the volume of blood and subsequently, blood pressure.
Choice B rationale
While regular exercise is beneficial for overall health, the statement “I should exercise for 30 minutes three times per week” may not be sufficient for hypertension prevention. The American Heart Association recommends at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity, or a combination of both, preferably spread throughout the week.
Choice C rationale
Eating fish once per week is not a specific recommendation for preventing hypertension. While fish can be a good source of lean protein and omega-3 fatty acids, it does not directly relate to blood pressure control.
Choice D rationale
The statement “With a BMI of 30, I should maintain my current weight” is incorrect. A BMI of 30 falls into the category of obesity, which is a risk factor for hypertension. Weight loss is recommended for hypertension prevention and control in overweight and obese individuals.
Correct Answer is A
Explanation
Choice A rationale
If 500 mL of fluid is removed during thoracentesis, the nurse should notify the provider. Removing large volumes of fluid can cause re-expansion pulmonary edema.
Choice B rationale
A clear chest x-ray is an expected finding after thoracentesis.
Choice C rationale
PCO2 is a measure of carbon dioxide levels in the blood. It is not directly related to thoracentesis.
Choice D rationale
Hematocrit is a measure of the proportion of red blood cells in the blood. It is not directly related to thoracentesis.
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