The first priority for a nurse caring for a client with a tracheostomy is:

Helping them communicate

Preventing them from developing an infection

Keeping their airway patent

Encouraging them to perform activities of daily living

Answer and Explanation

The Correct Answer is C

Choice A reason: Helping a tracheostomy client communicate is important for psychological well-being and care coordination, but it is not the priority. The ABCDE approach emphasizes airway patency first, as obstruction can lead to rapid respiratory failure. Communication aids, like speaking valves, are secondary to ensuring the tracheostomy tube remains clear and functional.

Choice B reason: Preventing infection is critical in tracheostomy care due to the open airway’s susceptibility to pathogens like Pseudomonas. However, in the ABCDE approach, airway patency is the top priority, as obstruction causes immediate respiratory compromise. Infection control, while essential, is addressed after ensuring the airway is open and functional.

Choice C reason: Keeping the airway patent is the first priority for a tracheostomy client. The tracheostomy tube can become obstructed by mucus or dislodgement, leading to rapid hypoxemia and respiratory arrest. Regular suctioning and monitoring ensure airflow, aligning with the ABCDE approach’s focus on airway as the most critical aspect of care.

Choice D reason: Encouraging activities of daily living promotes independence and recovery but is not the priority in tracheostomy care. The ABCDE approach prioritizes airway patency, as obstruction is life-threatening. Functional independence is addressed later, after ensuring airway, breathing, and circulation are stable, making this a lower-priority intervention.

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Correct Answer is A

Explanation

Choice A reason: Evaluating chest expansion assesses breathing, the second priority in the ABCDE approach. Trauma from a motor vehicle crash may cause rib fractures, pneumothorax, or hemothorax, impairing ventilation. Unequal or absent expansion indicates a life-threatening issue, requiring immediate intervention like chest tube placement to restore adequate respiration.

Choice B reason: Assessing capillary refill evaluates peripheral perfusion, a circulation parameter in the ABCDE approach. While important, it is secondary to airway and breathing. Trauma patients may have shock, but chest injuries affecting ventilation (e.g., pneumothorax) are more immediate threats, making chest expansion the first assessment to ensure respiratory function.

Choice C reason: Checking pupillary response assesses neurological status (disability in ABCDE), relevant for head trauma. However, breathing takes precedence over neurological assessment in trauma patients. Chest injuries can cause rapid respiratory failure, making chest expansion evaluation critical to identify life-threatening conditions like flail chest or pneumothorax before neurological checks.

Choice D reason: Checking orientation to place and time assesses neurological function, part of the disability component in ABCDE. While important in trauma, it is secondary to airway and breathing. Chest injuries from a crash can compromise ventilation, making chest expansion the priority to detect and address immediate respiratory threats before neurological evaluation.

A. Wear gowns, caps, masks, and gloves during care of the client B. Turn the room temperature up to at least 70°F (20°C) during dressing changes C. Use sterile gloves when removing old dressings D. Administer IV antibiotics to prevent bacterial colonization of wounds

Correct Answer is A

Explanation

Choice A reason: Full-thickness burns disrupt the skin barrier, increasing infection risk. Wearing gowns, caps, masks, and gloves creates a sterile barrier, preventing cross-contamination from healthcare workers or the environment. This adheres to strict infection control protocols, minimizing the introduction of pathogens like Staphylococcus or Pseudomonas to vulnerable burn wounds.

Choice B reason: Increasing room temperature to 70°F (20°C) during dressing changes aims to prevent patient hypothermia, as burns impair thermoregulation. However, this does not directly address cross-contamination. Temperature control is supportive but does not reduce microbial transmission, making it less effective than personal protective equipment for infection prevention.

Choice C reason: Using sterile gloves when removing old dressings reduces contamination during that specific task. However, it is less comprehensive than full personal protective equipment (gowns, caps, masks, gloves), which protects against contamination throughout care. Sterile gloves alone do not cover potential pathogen spread from other sources, like respiratory droplets or clothing.

Choice D reason: IV antibiotics treat or prevent systemic infections but do not directly prevent cross-contamination of exposed wounds. Prophylactic antibiotics may reduce bacterial colonization but are not the primary method for preventing environmental or contact-based contamination, which is better addressed by physical barriers like gowns and gloves.

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The first priority for a nurse caring for a client with a tracheostomy is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse in a trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Correct Answer is A

Explanation

While the client's full-thickness burn wounds to the face and body are exposed, what is the best nursing action to prevent cross-contamination?

Correct Answer is A

Explanation

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

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?

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?

The client with chronic renal failure has a glomerular filtration rate (GFR) of 40 mL/min/1.73 m², as measured by a 24-hour creatinine clearance. What is the nurse's interpretation of this finding?

A nurse is caring for a client with septic shock. The client’s blood pressure is 80/50 mm Hg, and lactate levels are elevated. Which intervention is the nurse’s priority?

A nurse is assessing a client with suspected hypovolemic shock following trauma. Which clinical finding is most indicative of this condition?

A client with chronic obstructive pulmonary disease (COPD) is admitted with acute exacerbation and respiratory distress. Which finding requires immediate intervention by the nurse?