A nurse is providing discharge teaching for the family of a client who had a tracheostomy inserted 2 months ago. Which of the following instructions should the nurse include?

"Use the clean technique when suctioning."

"Clean the stoma site with full-strength hydrogen peroxide."

"Decrease the humidity level in your home."

"Remove soiled tracheostomy ties before replacing them."

Answer and Explanation

The Correct Answer is A

Rationale:
A. "Use the clean technique when suctioning.": For a well-established tracheostomy (typically after 1 month), clean technique is acceptable for suctioning at home. This reduces infection risk while allowing practical self-care or family-provided care in a non-sterile environment.

B. "Clean the stoma site with full-strength hydrogen peroxide.": Full-strength hydrogen peroxide is too harsh and can damage healthy tissue. A diluted solution or normal saline is safer for routine stoma care to avoid irritation and promote healing.

C. "Decrease the humidity level in your home.": Adequate humidity is essential for clients with tracheostomies to keep secretions thin and prevent airway blockage. Low humidity can dry the airway and increase the risk of mucus plugs.

D. "Remove soiled tracheostomy ties before replacing them.": Tracheostomy ties should be replaced one side at a time to prevent accidental decannulation. Removing both sides at once leaves the tracheostomy tube unsecured and poses a serious safety risk.

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

Explanation

Rationale:

Chest tube output: A sudden stop in chest tube drainage following bright red output earlier can indicate tube obstruction or clot formation. This is concerning post-lobectomy, as blocked drainage may lead to tension pneumothorax or fluid accumulation.
Respiratory rate: A rate of 18/min is within normal limits and shows no signs of distress or compromise. Therefore, it does not require immediate reporting.
Trachea position: A shift from midline to deviated trachea suggests mediastinal shift, potentially due to a developing tension pneumothorax. This is a medical emergency and must be reported immediately.
Urine output: A urine output of 110 mL over one hour is well within normal limits and indicates adequate kidney perfusion. The expected minimum is 30 mL/hr, so this value does not raise concern for hypoperfusion or renal impairment. There is no need to report this finding to the provider at this time.
O₂ saturation: A drop from 92% to 89% on room air is clinically significant, especially after thoracic surgery. Hypoxia in this context may signal impaired lung function or emerging complications like pneumothorax.
Blood pressure: The client’s blood pressure dropped from 130/80 mm Hg to 110/60 mm Hg within one hour. While 110/60 mm Hg is still within normal range, the sudden 20 mm Hg drop in systolic pressure may indicate early hemodynamic instability, especially postoperatively.
Heart rate: A heart rate of 70/min is normal and stable, showing no signs of bradycardia or tachycardia that would warrant concern at this stage.
Temperature: A decrease in temperature from 37.2°C to 36.4°C is not clinically alarming postoperatively and does not suggest infection or hypothermia. No need for immediate reporting.

A. Coughing B. Flat neck veins C. Use of accessory muscles D. Presence of coarse crackles

Correct Answer is C

Explanation

Rationale:
A. Coughing: While coughing is a common symptom of asthma, it is not specific to status asthmaticus. It can occur during mild, moderate, or severe asthma episodes and does not necessarily indicate life-threatening severity.

B. Flat neck veins: Flat neck veins are not characteristic of status asthmaticus. In severe respiratory distress, the client may show signs of increased intrathoracic pressure, which can lead to distended neck veins rather than flat ones.

C. Use of accessory muscles: The use of accessory muscles to breathe is a sign of severe respiratory distress and indicates that the client is struggling to maintain adequate ventilation. This is a hallmark of status asthmaticus, a life-threatening condition requiring immediate intervention.

D. Presence of coarse crackles: Coarse crackles are more commonly associated with fluid in the lungs, such as in pneumonia or heart failure. In status asthmaticus, breath sounds may be diminished or absent due to severe airway obstruction, rather than producing crackles.

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A nurse is providing discharge teaching for the family of a client who had a tracheostomy inserted 2 months ago. Which of the following instructions should the nurse include?

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