Which nursing diagnosis is the priority when the nurse is caring for a patient with a traumatic brain injury who had a tracheostomy placed?
Ineffective airway clearance.
Risk for infection.
Risk for skin breakdown.
Impaired gas exchange.
The Correct Answer is A
Rationale:
A. Ineffective airway clearance is the priority because a patient with a tracheostomy is at immediate risk for obstruction from secretions, which can compromise breathing and oxygenation.
B. Risk for infection is important but not the most urgent; airway patency takes precedence over potential complications.
C. Risk for skin breakdown is relevant to long-term care but not life-threatening in the immediate postoperative period.
D. Impaired gas exchange may occur if the airway is not cleared, but ensuring airway clearance comes first in the nursing priority hierarchy (Airway-Breathing-Circulation).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. The position of the forearm can affect flow if the IV site becomes kinked or compressed.
B. The height of the IV bag/container directly affects gravity flow—the higher the bag, the faster the flow.
C. The relationship of angiocath size to the vein can influence resistance and flow rate.
D. The patient’s weight and height do not affect the gravity flow rate of an IV infusion, making this the correct exception.
Correct Answer is D
Explanation
Rationale:
A. Infiltration presents with swelling, pallor, coolness, and discomfort due to IV fluid leaking into surrounding tissue, not warmth and erythema.
B. Fluid overload manifests as dyspnea, crackles, edema, and hypertension, not localized site symptoms.
C. Sepsis involves systemic infection signs such as fever, chills, and hypotension, not just localized IV site changes.
D. It presents with tenderness, warmth, erythema, and pain along the vein due to inflammation of the vessel wall.
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