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.

Answer and Explanation

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.

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Correct Answer is ["1.5"]

Explanation

Step 1: Identify the order. The order is for 15,000 units of heparin.

Step 2: Identify the available medication. The available medication is heparin 10,000 units/mL.

Step 3: Calculate the dose. To find out how many mL to administer, divide the number of units ordered by the number of units per mL. So, 15,000 units ÷ 10,000 units/mL = 1.5 mL. So, the nurse should administer 1.5 mL of heparin with each dose.

A. Oxygen saturation B. Hemoglobin C. Mental status D. Urinary output E. WBC count

Correct Answer is ["C","E"]

Explanation

Choice A rationale:

Oxygen saturation is not provided in the exhibits, so there is no data available to evaluate if it indicates improvement in the client’s condition. While oxygen saturation is an important indicator of respiratory function and overall oxygenation status, its absence means it cannot be used to assess the client’s progress in this case.

Choice B rationale:

Hemoglobin levels decreased from 14 g/dL on postoperative day 1 to 10.5 g/dL on postoperative day 2. This decline in hemoglobin levels suggests that the client may be experiencing blood loss or anemia, which is not indicative of improvement. Generally, an improvement in the client’s condition would be reflected in stable or increasing hemoglobin levels rather than a decrease.

Choice C rationale:

Mental status is an important indicator of overall recovery and improvement. On postoperative day 2, the client is described as drowsy but alert to voice. This level of responsiveness indicates an improvement in mental status compared to what might be expected immediately post-surgery. A client who is drowsy but still responsive to verbal stimuli is showing signs of regaining consciousness and cognitive function, which is a positive sign of recovery.

Choice D rationale:

Urinary output is not provided in the exhibits, so there is no data available to assess if it indicates improvement. Urinary output is an important measure of kidney function and fluid status, but without specific data, it cannot be used to determine the client’s progress.

Choice E rationale:

The WBC count increased from 7,000/mm³ on day 1 to 8,500/mm³ on day 2, which is within the normal range and indicates a healthy immune response.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer heparin 15,000 units every 12 hr subcutaneously to a client who weighs 80 kg. Available is 10,000 units/mL. How many mL should the nurse administer with each dose?

Correct Answer is ["1.5"]

Explanation

Correct Answer is ["C","E"]

Explanation

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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?