The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Call for an assistant.

Respond to the code.

Finish the procedure.

Close the room door.

Answer and Explanation

The Correct Answer is A

Tracheostomy care is done to keep the trach tube clean and prevent infections. It involves suctioning and cleaning parts of the tube and the skin around the stoma. A code blue is a hospital emergency code that indicates a life-threatening situation, such as cardiac or respiratory arrest. It requires immediate attention from trained personnel.

According to the American Association of Critical-Care Nurses (AACN), the nurse should take the following action in this scenario:

Call for an assistant to stay with the client who is receiving tracheostomy care and continue the procedure.
Respond to the code blue and assist with resuscitation efforts for the other client.
Return to the client who is receiving tracheostomy care as soon as possible and complete the procedure.

Therefore, the correct answer is a. Call for an assistant.

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Correct Answer is ["A","B","D"]

Explanation

The correct answer isa. Place a bedside commode next to bed.,b. Measure neurological vital signs every 4 hours.,d. Encourage family to participate in the client’s care.

Choice A rationale:

Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.

Choice B rationale:

Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.

Choice C rationale:

Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management.Routine suctioning can also cause discomfort and potential injury.

Choice D rationale:

Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process.Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.

Choice E rationale:

Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation.The effectiveness of music therapy can vary based on individual preferences.

A. An adult who is in Buck's traction, and scheduled for hip arthroplasty within the next 12 hours. B. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection. C. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery. D. An adult one day postoperative laparoscopic cholecystectomy requesting pain medication.

Correct Answer is B

Explanation

A) Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention.
B) Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention.
C) Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.
D) Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding.

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The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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