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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:

Monitoring skin color is not specifically required for clients on ethambutol therapy. While changes in skin color can indicate various health issues, they are not directly related to the side effects of ethambutol.

Choice B reason:

Visual acuity should be monitored because ethambutol can cause optic neuropathy, which can lead to vision loss. Regular eye exams, including tests for visual acuity and color discrimination, are recommended to detect any early signs of optic nerve damage.

Choice C reason:

Monitoring cardiac rhythm is not specifically required for clients on ethambutol therapy. Ethambutol does not typically affect the heart’s rhythm. Cardiac monitoring would be more relevant for medications that have known cardiotoxic effects.

Choice D reason:

Monitoring urine output is not specifically required for clients on ethambutol therapy. While renal function should be monitored due to the drug’s excretion through the kidneys, urine output itself is not a primary concern unless there are signs of renal impairment.

A. Exhale quickly and forcefully through the mouth. B. Inhale sharply with a “huff” sound. C. Inhale deeply through pursed lips. D. Exhale slowly through pursed lips.

Correct Answer is D

Explanation

Pursed-lip breathing is a technique used to help manage shortness of breath and improve ventilation. It involves breathing in through the nose and exhaling slowly through pursed lips, as if blowing out a candle. This method helps to keep the airways open longer, allowing more air to escape and reducing the work of breathing.

Choice A reason:

Exhale quickly and forcefully through the mouth is not the correct intervention for pursed-lip breathing. Exhaling quickly and forcefully can cause the airways to collapse, making it harder to breathe out all the air. This can lead to air trapping and increased shortness of breath, which is counterproductive for clients with respiratory issues.

Choice B reason:

Inhale sharply with a “huff” sound is also not correct for pursed-lip breathing. Huff coughing is a technique used to clear mucus from the airways, not to manage breathing patterns. Inhaling sharply can cause irritation and may not provide the controlled breathing needed for effective gas exchange.

Choice C reason:

Inhale deeply through pursed lips is incorrect. The correct technique for pursed-lip breathing involves inhaling through the nose, not through pursed lips. Inhaling through the nose helps to filter and humidify the air, making it easier on the lungs and airways.

Choice D reason:

Exhale slowly through pursed lips is the correct intervention. This technique helps to prolong exhalation, which reduces the respiratory rate and improves ventilation. By keeping the airways open longer, it helps to release trapped air and improve oxygenation. This method is particularly beneficial for clients with chronic obstructive pulmonary disease (COPD) and asthma, as it helps to reduce the work of breathing and improve overall respiratory function.

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The nurse is preparing to perform tracheostomy care on a client diagnosed with COPD. Which action should the nurse complete first?

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Correct Answer is D

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