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 D

Explanation

A. Asking the provider to repeat another radiograph of the chest.

This option is not the most appropriate action in this scenario. While a chest radiograph may be useful in certain situations to assess for complications such as pneumothorax or pneumonia, it is not typically the first intervention for an asthma exacerbation with increased wheezing and decreased oxygen saturation. In this acute situation, the priority is to provide immediate treatment to alleviate the client's symptoms and improve oxygenation.

B. Increasing oxygen to maintain an oxygen saturation of 95% or greater in the client.

While maintaining adequate oxygenation is important, especially in a client with asthma exacerbation, it is not the first-line intervention in this scenario. Oxygen supplementation may be necessary, but the priority is to address the underlying bronchospasm causing the decreased oxygen saturation. Therefore, this option may be considered after initiating appropriate bronchodilator therapy.

C. Requesting the pharmacy to dispense 10 mL of dextromethorphan PO.

This option is not appropriate for managing an asthma exacerbation. Dextromethorphan is a cough suppressant and does not address the underlying bronchospasm characteristic of asthma exacerbations. In fact, suppressing cough may hinder the clearance of mucus and exacerbate respiratory distress. Therefore, this intervention is not indicated and may delay appropriate treatment.

D. Instructing respiratory therapy to administer a PRN albuterol aerosol.

This is the correct action in this scenario. Albuterol is a short-acting bronchodilator commonly used to relieve bronchospasm and improve airflow in clients experiencing asthma exacerbations. Administering albuterol via aerosolized inhalation helps to quickly deliver the medication directly to the airways, providing rapid relief of symptoms such as wheezing and improving oxygenation. Therefore, instructing respiratory therapy to administer a PRN albuterol aerosol is the most appropriate intervention to address the client's acute symptoms.

A. Oral mucosa B. Tip of the nose C. Ear lobes D. Eye lids

Correct Answer is A

Explanation

A. Oral mucosa:

The oral mucosa, including the inside of the mouth, tongue, and lips, is a reliable indicator of cyanosis. Cyanosis appears as a bluish discoloration of these tissues due to decreased oxygen saturation in the arterial blood. Assessing the oral mucosa is an essential component of clinical examination, especially in patients with respiratory conditions like asthma, as it provides valuable information about oxygenation status.

B. Tip of the nose:

While the tip of the nose may exhibit cyanosis in some cases, it is not considered as reliable of an indicator as the oral mucosa. The nasal tip is more susceptible to external factors such as cold temperatures or poor circulation, which can cause temporary discoloration. Therefore, it may not always accurately reflect the oxygenation status of the patient compared to the oral mucosa.

C. Ear lobes:

Cyanosis may be observed in the ear lobes in cases of severe hypoxemia, but it is not as reliable of an indicator as the oral mucosa. The ear lobes are less commonly assessed for cyanosis compared to other areas such as the lips, nail beds, or oral mucosa. While cyanosis may be present in the ear lobes, it is not typically the primary site assessed for oxygenation status.

D. Eyelids:

Cyanosis is not typically observed in the eyelids and is not considered a reliable indicator of hypoxemia. The eyelids are not commonly assessed for cyanosis during clinical examinations. While the conjunctiva (the lining inside the eyelids) may appear pale in cases of severe anemia, it is not a specific sign of hypoxemia. Assessment of the oral mucosa, lips, and nail beds is preferred for evaluating oxygenation status in patients with respiratory conditions like asthma.

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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?

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