The nurse is preparing to perform tracheostomy care on a client diagnosed with COPD. Which action should the nurse complete first?
Elevate the client’s head of the bed to 45 degrees.
Hyper-oxygenate the client using an Ambu bag.
Open the suction and tracheostomy kits.
Suction the client using aseptic technique.
The Correct Answer is B
Choice A reason: Elevating the client’s head of the bed to 45 degrees is important for promoting optimal lung expansion and reducing the risk of aspiration. However, it is not the first priority when preparing for tracheostomy care. Ensuring adequate oxygenation is more critical in the immediate preparation phase.
Choice B reason: Hyper-oxygenating the client using an Ambu bag is the first priority. This step is crucial to ensure that the client has sufficient oxygen reserves before the tracheostomy care procedure begins. Hyper-oxygenation helps prevent hypoxia during suctioning, which can be particularly important for clients with COPD who may already have compromised respiratory function.
Choice C reason: Opening the suction and tracheostomy kits is necessary for the procedure, but it should be done after ensuring the client is adequately oxygenated. Preparing the equipment is important, but patient safety and oxygenation take precedence.
Choice D reason: Suctioning the client using aseptic technique is a critical part of tracheostomy care to maintain a patent airway and prevent infection. However, this should be done after the client has been hyper-oxygenated to ensure they are stable and to minimize the risk of hypoxia during the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Hemoglobin, 8.0 g/dL: Hemoglobin is a critical component of red blood cells, responsible for carrying oxygen throughout the body. Normal hemoglobin levels typically range from 13.8 to 17.2 g/dL for men and 12.1 to 15.1 g/dL for women1. A level of 8.0 g/dL is significantly below the normal range, indicating anemia. Severe anemia can increase the risk of perioperative complications, including poor wound healing, increased risk of infection, and cardiovascular stress. Therefore, this result should be reported to the surgeon as it may necessitate postponing the surgery until the anemia is addressed.
Choice B reason:
Serum creatinine, 0.8 mg/dL: Creatinine is a waste product produced by muscles and filtered out of the blood by the kidneys. Normal serum creatinine levels range from 0.74 to 1.35 mg/dL for men and 0.59 to 1.04 mg/dL for women. A level of 0.8 mg/dL falls within the normal range, indicating normal kidney function. Therefore, this result would not typically cause surgery to be postponed.
Choice C reason:
Platelets, 210,000/mm³: Platelets are essential for blood clotting. Normal platelet counts range from 150,000 to 400,000/mm³. A count of 210,000/mm³ is within the normal range, indicating adequate clotting ability. Thus, this result would not be a reason to postpone surgery.
Choice D reason:
Sodium, 144 mEq/L: Sodium is an essential electrolyte that helps regulate fluid balance, nerve function, and muscle contractions. Normal sodium levels range from 135 to 145 mEq/L. A level of 144 mEq/L is within the normal range, indicating normal electrolyte balance. Therefore, this result would not typically cause surgery to be postponed.
Correct Answer is D
Explanation
Choice A reason:
A 36-year-old male who had a minimally invasive appendectomy and a history of community-acquired pneumonia a year ago is at relatively low risk for postoperative respiratory complications. Minimally invasive surgeries typically have fewer complications, and a past episode of pneumonia does not significantly increase the risk unless there are ongoing respiratory issues.
Choice B reason:
A 58-year-old female with type 1 diabetes who had an incision and drainage of an abscess with procedural sedation has some risk factors for complications, such as diabetes, which can impair healing and immune response. However, the procedure was minor and performed under sedation, which poses less risk compared to general anesthesia.
Choice C reason:
A 19-year-old male undergoing arthroscopic knee surgery under regional anesthesia with a history of exercise-induced asthma has a low risk of respiratory complications. Regional anesthesia does not affect the respiratory system as much as general anesthesia, and exercise-induced asthma is generally well-controlled and less likely to cause complications in this context.
Choice D reason:
A 65-year-old female with a BMI of 32 and a long history of tobacco use who underwent upper abdominal surgery under general anesthesia is at the greatest risk for respiratory complications. Factors such as advanced age, obesity, smoking history, and the type of surgery (upper abdominal) significantly increase the risk of postoperative pulmonary complications. General anesthesia further exacerbates this risk due to its effects on respiratory function.
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