A nurse is assisting with the care of a client who is 2 days postoperative following the creation of a tracheostomy. Which of the following actions should the nurse plan to take?

Place the client in left Sims' position.

Provide humidified air.

Clean the tracheostomy stoma with povidone-iodine.

Use clean technique when providing tracheostomy suctioning.

Answer and Explanation

The Correct Answer is B

A. Place the client in left Sims' position.

Left Sims' position is a lateral position used primarily for rectal examinations or procedures. It involves lying on the left side with the lower arm positioned behind the body and the upper knee flexed. This position is not indicated for a client post-tracheostomy. It does not provide any specific benefit for tracheostomy care and may not be comfortable or appropriate for a client recovering from tracheostomy surgery.

B. Provide humidified air.

Providing humidified air is crucial for clients post-tracheostomy to maintain moisture in the airway and prevent drying of secretions. Tracheostomy bypasses the upper airway's natural humidification mechanism, which can lead to drying of the mucous membranes and increased risk of complications such as mucus plugging and infection. Humidified air helps keep the secretions moist, facilitates their removal, promotes airway clearance, and reduces the risk of complications.

C. Clean the tracheostomy stoma with povidone-iodine.

While povidone-iodine is an antiseptic solution commonly used for skin preparation before invasive procedures, it is not typically used to clean the tracheostomy stoma, especially in the immediate postoperative period. Cleaning the stoma should be performed using sterile technique and appropriate solutions as directed by the healthcare provider. Using povidone-iodine may not be suitable for cleaning the tracheostomy stoma and could potentially irritate the area or introduce contaminants.

D. Use clean technique when providing tracheostomy suctioning.

Tracheostomy suctioning should always be performed using sterile technique to minimize the risk of introducing pathogens into the lower airway and causing infection. Clean technique, which involves washing hands and using clean gloves, is not appropriate for tracheostomy care, particularly in the immediate postoperative period when the risk of infection is higher. Sterile technique involves the use of sterile gloves, sterile suction catheters, and maintaining a sterile field to ensure the safety and cleanliness of the procedure.

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Correct Answer is B

Explanation

A. Administer IV morphine.

IV morphine may be indicated to relieve pain and anxiety associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

B. Begin oxygen therapy.

The priority intervention for a client who develops a pulmonary embolism is to begin oxygen therapy. Pulmonary embolism (PE) is a life-threatening condition characterized by a blockage in one or more of the pulmonary arteries, usually due to a blood clot. This blockage can lead to impaired gas exchange and decreased oxygenation of the blood, resulting in hypoxemia (low blood oxygen levels) and potentially leading to respiratory failure. Administering oxygen therapy promptly helps to improve oxygenation and support vital organ function. Therefore, it is the priority intervention to address the immediate respiratory distress associated with a pulmonary embolism.

C. Start an IV infusion of lactated Ringer's.

Intravenous fluid administration may be necessary to maintain hemodynamic stability and support perfusion in a client with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

D. Initiate cardiac monitoring.

Cardiac monitoring is important to assess for signs of cardiac compromise or dysrhythmias associated with a pulmonary embolism. However, it is not the priority intervention compared to addressing the client's respiratory distress and hypoxemia with oxygen therapy.

A. Assess the patient; check to see if the oxygen is flowing correctly B. Page the MD STAT C. Put up the patient's side rails and apply soft restraints D. Administer an IM sedative

Correct Answer is A

Explanation

A. Assess the patient; check to see if the oxygen is flowing correctly:

This option involves assessing the patient's condition promptly, particularly focusing on the adequacy of oxygenation. Checking the oxygen delivery system ensures that the patient is receiving the prescribed oxygen therapy at the appropriate flow rate. In a patient with shortness of breath (SOB) and increasing confusion and combativeness, hypoxemia (low oxygen levels) could be a contributing factor. Therefore, assessing the oxygen delivery system is crucial to ensure proper oxygenation and address potential causes of the patient's symptoms.

B. Page the MD STAT:

Paging the MD STAT may be necessary after assessing the patient's condition, especially if the patient's symptoms indicate a medical emergency or require immediate intervention. However, in this scenario, the priority is to assess the patient's condition and address any immediate concerns related to oxygenation and respiratory status. While paging the healthcare provider may be necessary, it should not delay the initial assessment and interventions needed to stabilize the patient.

C. Put up the patient's side rails and apply soft restraints:

Applying side rails and soft restraints should not be the first action in response to the patient's symptoms. While patient safety is important, these measures should only be implemented after other interventions have been attempted, and there is a risk of harm to the patient or others due to agitation or combativeness. In this case, the patient's confusion and combativeness may be secondary to hypoxemia, so addressing oxygenation and assessing the patient's condition are the immediate priorities.

D. Administer an IM sedative:

Administering a sedative should not be the first action in this scenario. Sedation may be considered if the patient's agitation or combativeness poses a risk to their safety or interferes with assessment and treatment. However, the underlying cause of the patient's symptoms, such as hypoxemia, should be addressed first. Administering a sedative without addressing the potential cause of the patient's symptoms could mask important clinical indicators and delay appropriate treatment.

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A nurse is assisting with the care of a client who is 2 days postoperative following the creation of a tracheostomy. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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