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 B

Explanation

Choice A reason: Thick secretions blocking airways are characteristic of conditions like chronic obstructive pulmonary disease or pneumonia, not pulmonary embolism. In pulmonary embolism, a clot obstructs pulmonary arteries, reducing blood flow to alveoli, not airflow. This leads to ventilation-perfusion mismatch, causing hypoxemia despite adequate breathing, making this explanation incorrect.

Choice B reason: A pulmonary embolism blocks pulmonary arteries, reducing blood flow to certain lung regions despite normal ventilation. This creates a ventilation-perfusion mismatch, where alveoli are ventilated but not perfused, leading to hypoxemia and respiratory distress. This is the primary mechanism of pulmonary embolism, making it the correct explanation for the family.

Choice C reason: This option suggests adequate blood flow but inadequate air to alveoli, which describes conditions like airway obstruction or atelectasis, not pulmonary embolism. In pulmonary embolism, the issue is reduced blood flow due to arterial obstruction, not insufficient air reaching alveoli, as breathing remains adequate, making this incorrect.

Choice D reason: Thickened alveolar-capillary membranes, impairing oxygen diffusion, occur in conditions like pulmonary fibrosis or edema, not pulmonary embolism. In pulmonary embolism, the primary issue is vascular obstruction, not membrane thickness, leading to reduced perfusion and hypoxemia despite normal alveolar structure, rendering this explanation scientifically inaccurate.

A. Administer IV antibiotics B. Initiate vasopressor therapy C. Obtain blood cultures D. Administer IV corticosteroids

Correct Answer is B

Explanation

Choice A reason: IV antibiotics are critical in septic shock to treat the underlying infection, but they take hours to act. Hypotension (80/50 mm Hg) and elevated lactate indicate tissue hypoperfusion, requiring immediate restoration of blood pressure. Vasopressors address shock more rapidly, making antibiotics secondary in the acute stabilization phase.

Choice B reason: Septic shock with blood pressure of 80/50 mm Hg and elevated lactate indicates severe hypoperfusion and tissue hypoxia. Vasopressor therapy, like norepinephrine, restores blood pressure, improving organ perfusion. The ABCDE approach prioritizes circulation, making vasopressors the immediate intervention to prevent organ failure and death in this critical condition.

Choice C reason: Obtaining blood cultures identifies the causative organism in septic shock, guiding antibiotic therapy. However, it does not address immediate hypotension and hypoperfusion, indicated by low blood pressure and high lactate. Vasopressors stabilize circulation first, making cultures a secondary step in the acute management of septic shock.

Choice D reason: IV corticosteroids may be used in refractory septic shock to support adrenal function, but they are not the first-line intervention. Hypotension and elevated lactate require immediate vasopressor therapy to restore perfusion. Corticosteroids are adjunctive and slower-acting, making them less critical than vasopressors in the initial stabilization of septic shock.

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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

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?

Correct Answer is B

Explanation

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?

Correct Answer is B

Explanation

This is an extra credit question: A nurse is caring for a client receiving hemodialysis. Exhibits A nurse is for a client who has received hemodialysis. Which of the following assessment findings require follow-up?

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

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