You are the RN caring for a patient with a tracheostomy tube. Which of the following will be included in your plan of care, related to the tracheostomy?
Turning/repositioning patient
Bathing patient
Assessing patency of tracheostomy tube
Providing bag mask ventilation to patient each shift
The Correct Answer is C
A. Turning/repositioning patient: While repositioning is important for overall patient care and to prevent pressure injuries, it is not specific to tracheostomy management and does not directly maintain airway patency.
B. Bathing patient: Bathing is part of routine hygiene care but does not relate directly to the function or safety of the tracheostomy tube.
C. Assessing patency of tracheostomy tube: Ensuring the tracheostomy tube is patent is critical to maintaining a clear airway, preventing obstruction, and ensuring adequate ventilation. Regular assessment includes checking for secretions, tube displacement, and airway obstruction.
D. Providing bag mask ventilation to patient each shift: Bag-mask ventilation is only indicated in emergencies when the patient is not ventilating adequately. Routine ventilation is not part of standard tracheostomy care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. He has acute respiratory failure on top of chronic respiratory failure (acute on chronic respiratory failure): The patient has a history of COPD, which can lead to baseline chronic respiratory compromise. The acute onset of cough, fever, shortness of breath, and SpO2 of 80% indicates a sudden worsening of gas exchange on top of chronic insufficiency.
B. Hypercapnic respiratory failure: While COPD patients are at risk for hypercapnic respiratory failure (elevated CO2), the key feature here is acute decompensation on a background of chronic disease, which encompasses hypoxemia and possibly hypercapnia.
C. An allergic reaction to a medication: Allergic reactions typically present with rash, swelling, or airway obstruction rather than fever, productive cough, and hypoxemia. This does not fit the patient’s presentation.
D. Heart failure: While heart failure can cause shortness of breath and hypoxemia, the presence of fever, cough, and a known COPD history makes an acute pulmonary process on top of chronic lung disease more likely than acute heart failure in this context.
Correct Answer is D
Explanation
A. Constipation: Constipation is a potential side effect of immobility or opioid use but is not directly related to mechanical ventilation or stiff lungs. It is a lower-priority concern in this context.
B. Unplanned extubation: While always a concern in ventilated patients, it is not specifically linked to the patient’s underlying pulmonary fibrosis or stiff lungs. Standard precautions can mitigate this risk.
C. Rapid respiratory rate: The ventilator controls respiratory rate in mechanically ventilated patients, and while tachypnea may occur with distress, it is less of a direct risk compared with complications from stiff lung tissue.
D. Barotrauma: Pulmonary fibrosis causes decreased lung compliance, meaning the lungs are stiff and less able to expand. Mechanical ventilation in stiff lungs increases the risk of barotrauma, such as pneumothorax, because the high pressures needed to ventilate noncompliant lungs can damage alveoli.
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