A nurse is performing tracheostomy care for a client who has a chronic tracheostomy. Which of the following actions should the nurse take?
Allow space for one finger to be placed under the tube ties.
Apply suction pressure while inserting the catheter into the trachea.
Suction the client for 20 seconds with each pass.
Cleanse around the stoma with povidone-iodine.
The Correct Answer is A
Choice A reason: Allowing space for one finger to be placed under the tube ties is a correct action for tracheostomy care. This ensures that the tube ties are not too tight, which can cause skin breakdown, pressure necrosis, or impaired circulation. The tube ties should also not be too loose, which can cause accidental dislodgement of the tube.
Choice B reason: Applying suction pressure while inserting the catheter into the trachea is an incorrect action for tracheostomy care. This can cause trauma to the tracheal mucosa and increase the risk of infection and bleeding. The nurse should apply suction pressure only while withdrawing the catheter and rotate it gently to remove secretions.
Choice C reason: Suctioning the client for 20 seconds with each pass is an incorrect action for tracheostomy care. This can cause hypoxia, bradycardia, or cardiac arrest due to vagal stimulation. The nurse should suction the client for no more than 10 to 15 seconds with each pass and allow at least 30 seconds between passes for oxygenation.
Choice D reason: Cleansing around the stoma with povidone-iodine is an incorrect action for tracheostomy care. Povidone-iodine is a strong antiseptic that can irritate the skin and cause allergic reactions. The nurse should cleanse around the stoma with normal saline or sterile water and apply a thin layer of water-soluble lubricant to protect the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because dyspnea, or difficulty breathing, is a sign of fluid overload that can occur during a blood transfusion due to excess volume or rapid infusion rate. The nurse should monitor the client's respiratory rate, oxygen saturation, and lung sounds and slow down or stop the transfusion if dyspnea occurs.
Choice B reason: This is not a sign of fluid overload, but a possible sign of anaphylaxis, which is a severe allergic reaction that can occur during a blood transfusion due to incompatibility or sensitivity to the donor blood. The nurse should monitor the client's pulse, blood pressure, and skin condition and stop the transfusion and administer epinephrine if anaphylaxis occurs.
Choice C reason: This is not a sign of fluid overload, but a possible sign of hemolytic reaction, which is a serious complication that can occur during a blood transfusion due to mismatched blood types or antibodies in the recipient's plasma that destroy the donor's red blood cells. The nurse should monitor the client's temperature, chills, and back pain and stop the transfusion and notify the provider if hemolytic reaction occurs.
Choice D reason: This is not a sign of fluid overload, but a possible sign of mild allergic reaction, which is a common but minor complication that can occur during a blood transfusion due to sensitivity to the donor's plasma proteins. The nurse should monitor the client's skin rash, itching, and hives and administer antihistamines as prescribed if mild allergic reaction occurs.
Correct Answer is A
Explanation
Choice A reason: This is the priority finding because an oral temperature of 39° C (102.2° F) can indicate thyroid storm or thyrotoxic crisis, which is a life-threatening complication of hyperthyroidism that causes severe hypermetabolism and organ dysfunction. The nurse should monitor the client's vital signs, administer antithyroid medications and beta blockers as prescribed, and provide cooling measures and supportive care.
Choice B reason: This is not a priority finding because a serum calcium level of 9.2 mg/dL is within the normal range of 8.5 to 10.2 mg/dL and does not indicate hypocalcemia or low calcium levels, which is a potential complication of total thyroidectomy due to accidental removal or damage of the parathyroid glands that regulate calcium metabolism. The nurse should monitor the client's serum calcium levels, assess for signs of hypocalcemia such as tingling, muscle spasms, or Chvostek's sign or Trousseau's sign, and administer calcium supplements as prescribed.
Choice C reason: This is not a priority finding because a moderate amount of serosanguineous drainage on dressings is an expected finding in the first 24 hours after surgery and does not indicate hemorrhage or infection, which are potential complications of total thyroidectomy. The nurse should inspect the dressings and wound site, measure and document the amount and color of drainage, and change the dressings as prescribed.
Choice D reason: This is not a priority finding because a report of a sore throat is an expected finding in the first 24 hours after surgery and does not indicate laryngeal nerve injury or airway obstruction, which are potential complications of total thyroidectomy. The nurse should assess the client's voice quality, respiratory status, and oxygen saturation, and provide analgesics, ice chips, or lozenges as prescribed.
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