The nurse is providing tracheostomy care for a client with a chronic tracheostomy, and the tube falls out. What priority action should the nurse initiate?

Notify the health care provider

Ventilate the client with a bag-valve-mask

Attempt to reinsert a new tracheostomy tube

Cover the stoma with an occlusive dressing

Answer and Explanation

The Correct Answer is C

Choice A reason: Notifying the provider delays airway restoration in a tracheostomy dislodgement. The priority is maintaining the airway, as the stoma may close rapidly in a chronic tracheostomy, risking respiratory distress, making immediate tube reinsertion critical over notification.

Choice B reason: Ventilating with a bag-valve-mask provides temporary oxygenation but does not address the dislodged tracheostomy tube. In a chronic tracheostomy, the stoma is the primary airway, and reinserting the tube prevents closure, making ventilation a secondary action.

Choice C reason: Attempting to reinsert a new tracheostomy tube is the priority, as chronic tracheostomy stomas may close rapidly, risking airway loss. Prompt reinsertion maintains patency, preventing respiratory distress or emergent surgical intervention, making this critical for client safety and breathing.

Choice D reason: Covering the stoma with an occlusive dressing risks airway obstruction in a chronic tracheostomy, where the stoma is the primary airway. This could lead to respiratory distress, as the client depends on the tracheostomy, making this incorrect compared to tube reinsertion.

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Correct Answer is B

Explanation

Choice A reason: Asking the UAP to reassess delays accurate assessment by a qualified nurse. Pulse 122 and BP 98/72 suggest tachycardia and hypotension, requiring professional validation and intervention, making this less appropriate than direct nurse reassessment and provider notification.

Choice B reason: Reassessing the client validates vital signs (pulse 122, BP 98/72), indicating tachycardia and hypotension, possibly from hypovolemia or sepsis. Accurate nurse assessment ensures reliable data for diagnosis, preventing complications like shock, making this a critical action in this scenario.

Choice C reason: Notifying the provider is essential, as tachycardia (pulse 122) and hypotension (BP 98/72) suggest serious conditions like hypovolemia or sepsis. Prompt reporting ensures timely interventions, such as fluids or diagnostics, preventing deterioration, making this necessary alongside reassessment.

Choice D reason: Sitting the client up may improve breathing but does not address tachycardia and hypotension, which suggest hypovolemia or other issues. These vital signs require reassessment and provider notification to diagnose and treat the cause, making positioning less urgent.

A. Wheezes B. Rhonchi C. Crackles D. Pleural friction rub

Correct Answer is B

Explanation

Choice A reason: Wheezes are high-pitched, musical sounds caused by narrowed airways, common in asthma or COPD exacerbations. They do not clear with coughing and are not moist or rumbling, making this an incorrect description for the lung sounds heard, which improve after coughing in this COPD client.

Choice B reason: Rhonchi are low-pitched, moist, rumbling sounds caused by secretions in larger airways, often in COPD. They improve with coughing as secretions are mobilized, matching the description provided. This makes rhonchi the accurate term for documenting these lung sounds, reflecting secretion accumulation in COPD.

Choice C reason: Crackles are fine or coarse popping sounds caused by fluid in smaller airways or alveoli, often in pneumonia or heart failure. They do not clear with coughing and are not rumbling, making crackles an incorrect choice for the moist, rumbling sounds that improve after coughing.

Choice D reason: Pleural friction rub is a grating sound caused by inflamed pleural surfaces, often in pleurisy. It is not moist or rumbling and does not improve with coughing, making it an inappropriate description for the lung sounds heard in this client with COPD, which are secretion-related.

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The nurse is providing tracheostomy care for a client with a chronic tracheostomy, and the tube falls out. What priority action should the nurse initiate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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