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 C

Explanation

Choice A reason: Infection is a significant risk in burns due to loss of the skin barrier, allowing pathogens like Pseudomonas to invade. However, in the acute phase, airway obstruction from head and neck burns is more immediately life-threatening. Infection control is critical but secondary to ensuring a patent airway in the ABCDE approach.

Choice B reason: Paralytic ileus can occur in burn patients due to stress response or hypokalemia, impairing gastrointestinal motility. While serious, it is not an immediate threat to life compared to airway obstruction. The ABCDE approach prioritizes airway, making ileus a lower priority in the acute management of head and neck burns.

Choice C reason: Extensive burns to the head, neck, and chest pose a high risk of airway obstruction due to edema from thermal injury to the upper airway. Swelling can rapidly compromise breathing, requiring urgent assessment and possible intubation. In the ABCDE approach, airway is the top priority, making this the critical focus.

Choice D reason: Fluid imbalance, particularly hypovolemia, is a major concern in burns due to plasma leakage. While critical, it is addressed after airway and breathing in the ABCDE approach. Airway obstruction from head and neck burns can cause rapid death, making it the priority over fluid resuscitation in the initial assessment.

A. Fluid intake for the last 24 hours B. Baseline arterial blood gas (ABG) levels C. Blood pressure and heart rate D. Electrocardiogram (ECG) results

Correct Answer is B

Explanation

Choice A reason: Fluid intake over 24 hours affects hydration and cardiovascular status but is not the primary parameter for ventilator weaning. Adequate fluid status supports hemodynamics, but weaning success depends on respiratory parameters like oxygenation and CO2 clearance, which are directly assessed by arterial blood gases, making fluid intake secondary.

Choice B reason: Baseline arterial blood gas (ABG) levels are critical before weaning from a ventilator. ABGs assess oxygenation (PaO2), CO2 levels (PaCO2), and acid-base balance, indicating the patient’s ability to maintain adequate ventilation and gas exchange independently. Normal or stable ABG values are essential to ensure successful weaning without respiratory failure.

Choice C reason: Blood pressure and heart rate reflect cardiovascular stability, which is important during weaning to ensure the patient tolerates increased respiratory effort. However, these are secondary to respiratory parameters. ABGs directly measure lung function, making them the priority to confirm the patient can breathe independently without ventilator support.

Choice D reason: Electrocardiogram (ECG) results assess cardiac rhythm and ischemia, which are relevant in critically ill patients. However, for ventilator weaning, the focus is on respiratory function. ECG abnormalities may warrant attention, but ABGs are the primary parameter to evaluate gas exchange and respiratory adequacy, making ECG less critical in this context.

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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 nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is C

Explanation

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

Correct Answer is B

Explanation

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