The critical care nurse recognizes that which of the following conditions may indicate the need for a client to have a tracheostomy?

A client with a respiratory rate of 10 breaths/min

A client who requires permanent ventilation

A client who exhibits symptoms of dyspnea

A client with respiratory acidosis

Answer and Explanation

The Correct Answer is B

Choice A reason: A respiratory rate of 10 breaths/min is slightly below normal (12-20 breaths/min) but may not necessitate a tracheostomy unless accompanied by other factors like airway obstruction or inability to protect the airway. Tracheostomy is typically reserved for prolonged ventilation needs, not isolated low respiratory rates.

Choice B reason: A client requiring permanent ventilation, such as in chronic neuromuscular diseases or severe lung injury, needs a tracheostomy to provide a stable, long-term airway. Unlike endotracheal tubes, tracheostomies reduce complications like vocal cord damage and improve patient comfort, making them the standard for prolonged mechanical ventilation.

Choice C reason: Dyspnea, or shortness of breath, indicates respiratory distress but does not inherently require a tracheostomy. It may be managed with oxygen or non-invasive ventilation. Tracheostomy is indicated for airway obstruction or prolonged ventilation, not transient symptoms like dyspnea, which can have multiple causes.

Choice D reason: Respiratory acidosis, due to elevated CO2 from hypoventilation, may require ventilatory support but not necessarily a tracheostomy. Non-invasive ventilation or temporary intubation may suffice. Tracheostomy is reserved for long-term airway management, making it less relevant for acute acidosis without evidence of prolonged ventilation needs.

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Correct Answer is B

Explanation

Choice A reason: Observing mist in the endotracheal tube suggests air movement but is not a reliable indicator of correct placement. Mist can occur with esophageal intubation or partial airway placement. Definitive confirmation requires imaging, as mist does not distinguish between tracheal and esophageal placement, risking ventilation errors.

Choice B reason: A chest x-ray is the gold standard for confirming endotracheal tube placement. It visualizes the tube’s position relative to the carina, ensuring it is in the trachea and not the esophagus or a main bronchus. This is critical in pulmonary edema to ensure effective ventilation and oxygenation.

Choice C reason: Attaching a pulse oximeter monitors oxygen saturation but does not confirm endotracheal tube placement. Improved saturation may occur with incorrect placement (e.g., esophageal), and low saturation does not specify tube position. Imaging is required for definitive confirmation, making pulse oximetry a supportive, not primary, measure.

Choice D reason: Checking the pH of secretions is not a standard method for confirming endotracheal tube placement. Secretions’ pH varies and does not indicate whether the tube is in the trachea or esophagus. Chest x-ray provides anatomical confirmation, essential for ensuring proper ventilation in critical conditions like pulmonary edema.

A. A client with smoke inhalation who has wheezes and altered mental status B. A client with 40% total body surface area (TBSA) burns who is receiving IV fluids at 250 mL/hour C. A client with full thickness leg burns who has a dressing change scheduled D. A client with abdominal burns who is complaining of level 8 (0 to 10 scale) pain

Correct Answer is A

Explanation

Choice A reason: Smoke inhalation with wheezes and altered mental status indicates potential airway compromise and hypoxemia, critical in the ABCDE approach. Wheezing suggests bronchospasm or edema, and altered mental status may reflect cerebral hypoxia or carbon monoxide poisoning, requiring immediate assessment and intervention to secure the airway and restore oxygenation.

Choice B reason: A client with 40% TBSA burns receiving IV fluids at 250 mL/hour is being treated for hypovolemia, a circulation issue in the ABCDE approach. While serious, this client is stable with ongoing treatment. Airway and breathing issues, as in smoke inhalation with altered mental status, take precedence due to rapid lethality.

Choice C reason: Full-thickness leg burns with a scheduled dressing change address infection risk and wound care, which are important but not immediate priorities. The ABCDE approach prioritizes airway and breathing over wound management. Smoke inhalation with neurological changes indicates a more urgent threat to life, requiring assessment before routine procedures.

Choice D reason: Level 8 pain in abdominal burns is significant and requires management, but pain is addressed after airway, breathing, and circulation in the ABCDE approach. Smoke inhalation with wheezes and altered mental status suggests airway compromise and hypoxemia, which are more immediate threats, making pain control a lower priority.

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The critical care nurse recognizes that which of the following conditions may indicate the need for a client to have a tracheostomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in severe pulmonary edema is being intubated by the resident. What action by the nurse will assist in the confirmation of the endotracheal tube placement in the proper position?

Correct Answer is B

Explanation

The nurse receives change-of-shift report on the following four clients in a burn unit. Which client should the nurse assess first?

Correct Answer is A

Explanation

Question 28

In an emergency department, a nurse is presented with four clients. Which client should the nurse prioritize based on the ABCDE approach?

A client with cirrhosis is admitted with hematemesis and tachycardia. The nurse suspects variceal bleeding. Which action should the nurse take first?

The emergency room nurse is assigned the following clients at the beginning of their shift. Which client does the nurse see first?

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his neck, chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation phase of injury?

Before weaning a client from a ventilator, which assessment parameter(s) is most important for the nurse to assess?

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

A client is diagnosed with a large pulmonary embolism. When explaining what has happened to cause respiratory distress to the client's family, which information will the nurse include?