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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5"]
Explanation
Step 1 is (2 grams ÷ 10 mL) Result = 0.2 grams per mL
Step 2 is (1 gram ÷ 0.2 grams per mL) Result = 5 mL
Correct Answer is B
Explanation
Choice A reason: A basic metabolic panel assesses electrolytes and renal function but does not identify the bacterial cause of pneumonia. It supports overall patient status but does not guide antibiotic selection, making it less critical than sputum culture for ensuring targeted, effective antibiotic therapy.
Choice B reason: Sputum culture and sensitivity identify the specific bacteria causing pneumonia and their antibiotic susceptibilities, ensuring targeted therapy. Inappropriate antibiotics risk treatment failure and resistance. Obtaining the culture before antibiotics prevents false-negative results, making this critical for effective treatment.
Choice C reason: A chest radiograph confirms pneumonia’s presence and extent but does not identify the causative organism or antibiotic sensitivity. It supports diagnosis but does not guide specific antibiotic therapy, making it less critical than sputum culture for ensuring appropriate treatment.
Choice D reason: A complete blood count with differential shows infection severity (e.g., elevated white cells) but does not identify specific bacteria or antibiotic sensitivity. It supports diagnosis but is secondary to sputum culture, which ensures targeted antibiotic selection for effective pneumonia treatment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.