The nurse is caring for a client with a new tracheostomy. Which action is most important to include in the client’s plan of care?

Change the tracheostomy ties every 48 hours.

Suction the tracheostomy every 2 hours routinely.

Assess airway patency every shift.

Clean the inner cannula with hydrogen peroxide daily.

Answer and Explanation

The Correct Answer is C

Choice A reason: Changing tracheostomy ties every 48 hours maintains hygiene but is less critical than airway patency. Ties secure the tube, but obstruction from mucus or dislodgement risks respiratory failure. Regular patency checks ensure airflow, addressing the primary physiological need for oxygenation in tracheostomy care.

Choice B reason: Routine suctioning every 2 hours is unnecessary unless secretions obstruct the airway. Over-suctioning risks mucosal trauma or hypoxia. Assessing patency ensures the airway remains clear, guiding suctioning as needed, prioritizing respiratory function in tracheostomy clients over arbitrary suction schedules.

Choice C reason: Assessing airway patency every shift is critical, as tracheostomy tubes risk obstruction from mucus or dislodgement, causing respiratory distress. Regular checks confirm airflow, preventing hypoxia, addressing the physiological priority of oxygenation. This ensures timely intervention, maintaining airway integrity in clients with artificial airways.

Choice D reason: Cleaning the inner cannula daily prevents infection but is secondary to airway patency. Obstruction from secretions or tube displacement causes immediate respiratory failure. Patency assessment ensures airflow, guiding cleaning as needed, making it more urgent than routine cannula maintenance in tracheostomy care.

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Correct Answer is A

Explanation

Choice A reason: Depression involves social withdrawal, driven by low serotonin or dopamine. Encouraging the client to leave the room and engage socially stimulates oxytocin release and cognitive behavioral benefits, counteracting isolation. This therapeutic approach enhances mood and aligns with depression management goals, making it the most effective response.

Choice B reason: Calling TV a passive activity is partially true but less therapeutic, as it doesn’t directly promote social engagement. Depression treatment prioritizes interpersonal interaction to boost neurotransmitters like serotonin. This response misses the opportunity to encourage social therapy, critical for alleviating depressive symptoms in a mental health setting.

Choice C reason: Suggesting TV sends messages is inappropriate without psychotic symptoms, not indicated in this client’s depression. Depression involves low mood, not delusions. This could confuse or stigmatize, failing to promote social engagement, which is essential for improving mood via neurochemical and behavioral pathways in depression management.

Choice D reason: Allowing unlimited TV outside the room does not address depression’s social isolation. Excessive TV may reinforce withdrawal, reducing therapeutic group activities that enhance serotonin. This lacks focus on active engagement, critical for recovery, making it less effective than encouraging social interaction to improve mental health outcomes.

A. Ensure supplemental oxygen and respiratory medications are available at all times. B. Use nasal or cough tissues followed by handwashing at all times. C. Avoid large crowded areas during the colder months of the year. D. Get annual flu and Pneumococcal vaccine polyvalent (PPSV23) vaccines.

Correct Answer is D

Explanation

Choice A reason: Ensuring oxygen and medications manages exacerbations in asthma, bronchitis, and emphysema, where airway inflammation obstructs breathing. These treat symptoms, not prevent infections. Vaccines reduce influenza and pneumococcus, major exacerbation triggers, providing specific immunity to prevent severe respiratory infections, making them a higher priority.

Choice B reason: Using tissues and handwashing reduces infection spread but is less effective than vaccines for preventing exacerbations in chronic lung diseases. Influenza and pneumococcus trigger severe bronchoconstriction or inflammation. Vaccines offer targeted protection against these pathogens, prioritizing prevention over general hygiene in high-risk clients.

Choice C reason: Avoiding crowded areas in colder months reduces viral exposure, which can exacerbate asthma or COPD via inflammation. Vaccines are more effective, providing specific immunity against influenza and pneumococcus, the most common triggers of severe exacerbations, making this less critical than vaccination for preventing respiratory complications.

Choice D reason: Annual flu and PPSV23 vaccines are critical for asthma, bronchitis, and emphysema, as these conditions increase severe infection risk. Influenza and pneumococcus trigger exacerbations via airway inflammation, risking hospitalization. Vaccines stimulate antibody production, reducing infection severity, making them the top preventive measure for chronic lung disease management.

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The nurse is caring for a client with a new tracheostomy. Which action is most important to include in the client’s plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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