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 D

Explanation

A.While pain management is important, it is not the most critical intervention compared to monitoring for bleeding, which can be life-threatening.

B.Teaching the client how to use incentive spirometry is important for improving lung function and preventing complications like atelectasis. However, in the context of a pulmonary embolism (PE), the immediate priority is to monitor for signs of increased bleeding due to the anticoagulant or thrombolytic therapy often used to treat PE. This is crucial to prevent potentially life-threatening complications.

C.Confusion and restlessness could indicate hypoxia, which is important to monitor in a PE patient. However, the immediate risk of bleeding due to anticoagulation therapy takes precedence.

D.Patients with a pulmonary embolism are typically treated with thrombolytic or anticoagulant therapy to prevent further clot formation and to help dissolve the existing clot. Anticoagulants significantly increase the risk of bleeding, making it crucial to monitor for signs of increased bleeding as a priority in the plan of care.

A. Transfuse two units packed red blood cells. B. Administer ampicillin 2 grams intravenously. C. Inject hepatitis B immune globulin 0.5 mL. D. Give measles, mumps, rubella vaccine 0.5 mL.

Correct Answer is B

Explanation

The client's labs indicate that she has a positive result for group B Streptococcus (GBS) and hepatitis surface antigen, and she is also identified as rubella non-immune.

Ampicillin is the recommended antibiotic for intrapartum prophylaxis against GBS infection to reduce the risk of transmission to the newborn. Administering ampicillin intravenously would help protect the newborn from potential GBS-related complications. Transfusion of packed red blood cells is not indicated based on the hemoglobin and hematocrit values provided. The client's hemoglobin and hematocrit levels, although lower than the reference range, are not critically low and do not necessarily require a blood transfusion.

Injecting hepatitis B immune globulin is not the appropriate intervention in this case. The client is positive for hepatitis surface antigen, indicating active infection, and requires appropriate medical management, which may include antiviral treatment.

Administering the measles, mumps, rubella vaccine is contraindicated during pregnancy. Vaccination for rubella is typically recommended prior to conception or postpartum to prevent congenital rubella syndrome.

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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

After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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