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 A

Explanation

Choice A reason: Hypovolemia is likely, as vomiting and diarrhea cause significant fluid loss, leading to dehydration. Confusion (from cerebral hypoperfusion), elevated temperature (from concentrated blood), and dry mouth (from reduced saliva) reflect low intravascular volume, making this the most fitting diagnosis for the client’s condition.

Choice B reason: Hypernatremia results from excessive sodium relative to water, often from inadequate water intake. Vomiting and diarrhea deplete water and electrolytes, causing hypovolemia, not sodium excess. Confusion and fever align with dehydration, making hypernatremia an incorrect diagnosis in this scenario.

Choice C reason: Hypokalemia may occur with diarrhea due to potassium loss, but confusion, fever, and dry mouth primarily reflect hypovolemia from fluid loss. Potassium loss is secondary, as hypovolemia’s systemic effects are more immediate, making this a less comprehensive diagnosis for the client’s symptoms.

Choice D reason: Metabolic acidosis can occur with diarrhea due to bicarbonate loss, but confusion, fever, and dry mouth primarily reflect hypovolemia from fluid loss. Acidosis may contribute, but hypovolemia drives these systemic signs, making it the more accurate diagnosis in this context.

Correct Answer is []

No explanation

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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 A

Explanation

Correct Answer is []

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