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 D
Explanation
Choice A rationale:
Positioning the patient in semi-Fowler's position (Choice A) is an important step in tracheostomy care, but it is not the first step during the suctioning procedure. Semi-Fowler's position helps promote lung expansion and allows for better visualization during the procedure.
Choice B rationale:
Applying a new dressing around the stoma (Choice B) is essential after suctioning to maintain cleanliness and prevent infection. However, it is not the first step in the suctioning procedure. The nurse should first gather the necessary equipment.
Choice C rationale:
Cleaning the inner cannula with hydrogen peroxide (Choice C) is not the first step during suctioning. The nurse should gather equipment and supplies first before performing any cleaning or other procedures.
Choice E rationale:
Removing the old dressing and discarding it in a moisture-resistant bag (Choice E) is an important step, but it should come after the nurse gathers the necessary equipment for the suctioning procedure.
Correct Answer is B
Explanation
Choice A rationale:
Performing tracheostomy care every 2 to 4 hours would be too frequent for most patients and may cause unnecessary disruption and discomfort. This interval is not the recommended standard of care.
Choice B rationale:
Tracheostomy care every 4 to 6 hours strikes a balance between maintaining airway hygiene and minimizing excessive handling of the tracheostomy site, reducing the risk of complications such as infection or irritation.
Choice C rationale:
Waiting to perform tracheostomy care every 6 to 8 hours may increase the risk of mucus buildup and potential complications, especially in patients with high secretions or respiratory issues.
Choice D rationale:
Extending the interval to every 8 to 12 hours may lead to inadequate airway clearance and increased risk of complications in patients who require more frequent care.
Choice E rationale:
Waiting to perform tracheostomy care every 12 to 24 hours is too infrequent for most patients and may not be sufficient to maintain a patent airway and prevent complications.
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.