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 C

Explanation

A. Nausea

While nausea can occur in hypoxia, it is less common compared to other symptoms such as dyspnea (difficulty breathing), confusion, or cyanosis (bluish discoloration of the skin and mucous membranes).

B. Dysphagia

Dysphagia, or difficulty swallowing, is not typically associated with hypoxia. It is more commonly seen in conditions affecting the esophagus or neurological disorders affecting swallowing function.

C. Agitation

Manifestations of hypoxia can vary depending on the severity and duration of oxygen deprivation. Agitation is a common finding in hypoxia, particularly in cases of acute or severe hypoxemia. As the body's oxygen supply becomes compromised, the brain may perceive this as a threat, leading to increased anxiety, restlessness, and agitation as the body attempts to compensate for the lack of oxygen.

D. Warm, dry skin

Warm, dry skin is not a typical finding in hypoxia. Instead, hypoxia may lead to peripheral vasoconstriction and cool, clammy skin as the body attempts to conserve oxygen and maintain core body temperature.

A. Rest in a supine position. B. Consume a low-protein diet. C. Breathe in through her nose and out through pursed lips. D. Limit fluid intake throughout the day.

Correct Answer is C

Explanation

A. Rest in a supine position.

This option is not recommended for improving gas exchange in emphysema. Resting in a supine position can lead to decreased lung expansion and increased dyspnea in individuals with emphysema. Optimal lung expansion is crucial for efficient gas exchange, and certain positions, such as sitting upright or using pillows to support the head and chest, are preferred to facilitate breathing.

B. Consume a low-protein diet.

A low-protein diet is not directly related to improving gas exchange in emphysema. In fact, adequate protein intake is important for maintaining overall health and supporting respiratory muscle function. Protein is necessary for tissue repair and maintaining muscle strength, including the respiratory muscles. Therefore, a balanced diet that includes adequate protein intake is recommended for individuals with emphysema.

C. Breathe in through her nose and out through pursed lips.

This is the correct choice. Breathing in through the nose and out through pursed lips helps to create positive pressure in the airways during exhalation. This positive pressure helps to keep the airways open, prevents premature collapse of the air sacs (alveoli), and facilitates more effective gas exchange. It also slows down the rate of breathing, reduces the work of breathing, and can alleviate shortness of breath (dyspnea) in individuals with emphysema.

D. Limit fluid intake throughout the day.

Limiting fluid intake throughout the day is not recommended for improving gas exchange in emphysema. Adequate hydration is important for thinning respiratory secretions, which can make it easier to clear mucus from the airways. Dehydration can worsen respiratory symptoms and increase the risk of complications. Therefore, maintaining adequate fluid intake is essential for individuals with emphysema.

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