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
While it’s important to prepare for a colonoscopy by cleaning out the colon, drinking full liquids until 6 hours before the procedure may not be recommended. The colon needs to be empty to allow the doctor to view it clearly during the colonoscopy. Therefore, this choice is incorrect.
Choice B rationale
Moderate sedation is often used during a colonoscopy. This means you’ll be relaxed and somewhat drowsy, but you’ll still be awake. You might not remember much about the actual procedure because of the sedative. Therefore, this choice is correct.
Choice C rationale
During a colonoscopy, you will likely start by lying on your left side. However, you may be asked to adjust your position during the procedure to allow the doctor to better examine certain parts of your colon. Therefore, this choice is incorrect.
Choice D rationale
Warming the liquid bowel preparation before drinking it is not typically recommended. The bowel preparation involves drinking a solution that helps clear out the colon, but it doesn’t need to be warmed. Therefore, this choice is incorrect.
Correct Answer is B
Explanation
Choice A rationale
Starting chest compressions is not the first action to take when a client’s cardiac monitor shows ventricular tachycardia. While chest compressions are a part of cardiopulmonary resuscitation (CPR), they are not the initial response to ventricular tachycardia.
Choice B rationale
Immediate defibrillation is the priority action when a client’s cardiac monitor shows ventricular tachycardia. Ventricular tachycardia is a life-threatening condition where the heart
beats too fast to effectively pump blood to the body. Defibrillation delivers an electrical shock to the heart, which aims to restore a normal heart rhythm.
Choice C rationale
Providing pulmonary ventilation is not the first action to take when a client’s cardiac monitor shows ventricular tachycardia. While ventilation is important, it is not the immediate priority in this situation.
Choice D rationale
Checking for a palpable pulse is not the first action to take when a client’s cardiac monitor shows ventricular tachycardia. While it is important to assess the client’s pulse, the priority is to restore a normal heart rhythm through defibrillation.
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.