A nurse is caring for a patient with a tracheostomy. The patient suddenly develops bright red bleeding from the tracheostomy stoma, pulsation of the tracheostomy tube in synchrony with the heartbeat, hypotension, and tachycardia. What should the nurse do first?
Notify the health care provider immediately.
Apply direct pressure to stop bleeding.
Administer fluids and blood products as ordered.
Ensure proper positioning and alignment of the tracheostomy tube.
The Correct Answer is B
Choice A rationale:
While notifying the healthcare provider is essential, the priority action in this situation is to stop the bleeding to prevent further complications.
Choice B rationale:
Applying direct pressure to the tracheostomy stoma is the first action the nurse should take to control the bleeding and stabilize the patient.
Choice C rationale:
Administering fluids and blood products may be necessary later, but it is not the first action to take when dealing with active bleeding.
Choice D rationale:
Ensuring proper positioning and alignment of the tracheostomy tube is important, but it is not the priority in this critical situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Choice A rationale:
Sterile gloves are essential for aseptic technique during tracheostomy suctioning to prevent the introduction of infection. However, they are not included in the setup, as they are worn by the nurse performing the procedure.
Choice B rationale:
Sterile water or saline is necessary for suctioning to moisten the suction catheter and facilitate the removal of secretions without causing trauma to the airway. Therefore, it should be included in the setup.
Choice C rationale:
A pulse oximeter is used to monitor the patient's oxygen saturation and is not directly related to tracheostomy suctioning. While continuous monitoring of oxygen saturation is essential during and after the procedure, it is not a part of the setup.
Choice D rationale:
A sphygmomanometer is used to measure blood pressure and is unrelated to tracheostomy suctioning. It is not required for this procedure.
Choice E rationale:
A non-sterile towel is used to protect the patient's clothing and bed linens from any secretions or spills during the suctioning procedure. It should be included in the setup to maintain cleanliness and prevent contamination.
Correct Answer is ["B","C"]
Explanation
Choice A rationale:
This statement is correct. The client should inform the nurse if they notice any food particles in their tracheal secretions as it could indicate aspiration and require immediate attention.
Choice B rationale:
This statement indicates a need for further education. A larger tracheostomy tube to prevent an air leak at the stoma is not an appropriate intervention for tracheomalacia. Tracheomalacia is the weakening of the tracheal cartilage, and a larger tube would not address this underlying issue.
Choice C rationale:
This statement is also incorrect. Minimizing the time the cuff is inflated may be beneficial to prevent tracheal stenosis but would not prevent tracheomalacia, which is a different condition altogether.
Choice D rationale:
This statement is correct. Monitoring cuff pressure and air volumes closely is essential to prevent complications and ensure appropriate cuff inflation.
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.