The nurse is caring for a client with a new tracheostomy. What will the nurse prioritize for care?

Reducing the client’s anxiety concerning self-care of the tracheostomy

Reassuring the client that the tracheostomy is a temporary measure

Ensuring that the skin around the client’s tracheostomy stoma is assessed frequently

Referring the client to a support group for individuals with tracheostomies

Answer and Explanation

The Correct Answer is C

Choice A reason: Reducing anxiety about tracheostomy self-care aids long-term adjustment but is not the immediate priority. A new tracheostomy requires vigilant monitoring for complications like infection or skin breakdown at the stoma, which can lead to serious infections or tissue damage if not addressed promptly.

Choice B reason: Reassuring the client that the tracheostomy is temporary may provide emotional support but is not the priority. Many tracheostomies are permanent, and assuming temporariness may mislead. Immediate care focuses on preventing complications like stoma infections, making skin assessment more critical than reassurance.

Choice C reason: Frequent assessment of the skin around the tracheostomy stoma prevents complications like infection, pressure ulcers, or tissue necrosis. The stoma is prone to irritation from secretions and tube movement, which can foster bacterial growth and skin breakdown, necessitating vigilant monitoring to ensure healing and prevent serious infections.

Choice D reason: Referring to a support group aids long-term coping but is not the immediate priority. A new tracheostomy requires focus on preventing physical complications like infection or skin breakdown at the stoma, which pose immediate risks, making skin assessment more urgent than psychosocial support.

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Correct Answer is B

Explanation

Choice A reason: Rolled gauze and sterile saline are used for general wound care but are inadequate for chest tube emergencies. If a tube dislodges, an occlusive dressing prevents air entry into the pleural space, avoiding pneumothorax, making this choice insufficient for emergency preparedness in chest tube management.

Choice B reason: A petrolatum-impregnated sterile occlusive dressing is critical for chest tube emergencies. If the tube dislodges, it seals the pleural space, preventing air entry and reducing pneumothorax risk. This ensures immediate response to maintain lung function, making it the priority supply for emergency preparedness.

Choice C reason: Suction tubing and Yankauer suction tip clear oral or airway secretions, not chest tube issues. They are irrelevant for emergencies like tube dislodgement, where sealing the pleural space prevents pneumothorax, making this choice inappropriate for chest tube emergency preparedness in this scenario.

Choice D reason: Non-adhesive dressings and tracheostomy tubes are for tracheostomy care, not chest tubes. They do not address emergencies like tube dislodgement, which require an occlusive dressing to prevent air entry, rendering this choice incorrect for chest tube emergency preparedness in this context.

A. A 46-year-old with a 30-pack-year history of smoking B. A 52-year-old in a tripod position using accessory muscles to breathe C. A 68-year-old who has dependent edema and clubbed fingers D. A 55-year-old with a chronic cough and thick secretions

Correct Answer is B

Explanation

Choice A reason: A 30-pack-year smoking history indicates COPD risk but not acute distress. Smoking is a chronic factor, not an immediate symptom requiring urgent assessment. Clients with active respiratory distress, like accessory muscle use, take priority due to immediate risks of hypoxia.

Choice B reason: A 52-year-old in a tripod position using accessory muscles indicates severe respiratory distress in COPD, reflecting hypoxia or hypercapnia. This posture and muscle use signal increased work of breathing, requiring immediate assessment to prevent respiratory failure, making this client the highest priority.

Choice C reason: Dependent edema and clubbed fingers in a 68-year-old suggest chronic COPD with possible cor pulmonale. These are chronic findings, not acute distress. Clients with immediate respiratory compromise, like accessory muscle use, take priority due to the risk of rapid decompensation.

Choice D reason: Chronic cough with thick secretions is common in COPD but less urgent than acute respiratory distress. Secretions contribute to airway obstruction, but tripod positioning and accessory muscle use indicate immediate hypoxia risk, requiring priority assessment over chronic symptoms.

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The nurse is caring for a client with a new tracheostomy. What will the nurse prioritize for care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a chest tube. Which supplies should the nurse ensure are readily available at the client's bedside for emergencies?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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