A nurse is caring for a client who has a tracheostomy. When providing tracheostomy care, which of the following actions should the nurse perform first?
Change the dressing on the tracheostomy site.
Suction the tracheostomy tube.
Auscultate the client's lungs.
Clean the inner cannula.
The Correct Answer is B
A. Change the dressing on the tracheostomy site: Although changing the dressing is an important part of tracheostomy care, it should be performed after ensuring that the airway is patent and clear. The priority is to maintain an open airway and prevent obstruction.
B. Suction the tracheostomy tube: Suctioning the tracheostomy tube should be performed first to clear any secretions or obstructions that could impair breathing. Ensuring the airway is clear is critical before proceeding with other care tasks.
C. Auscultate the client's lungs: While auscultation is important for assessing lung sounds and the overall respiratory status, it is secondary to ensuring the tracheostomy tube is clear. The priority is to address any potential airway obstructions first.
D. Clean the inner cannula: Cleaning the inner cannula is an essential part of tracheostomy care, but it should be done after ensuring the airway is clear and patent. Prioritizing suctioning ensures that the cannula can be cleaned effectively without interference from secretions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ammonia 55 mcg/dL (10 to 80 mcg/dL): This value is within the normal range and does not indicate an immediate concern for a liver biopsy.
B. Platelets 60,000/mm³ (150,000 to 400,000/mm³): This value is significantly below the normal range and indicates thrombocytopenia, which increases the risk of bleeding during a liver biopsy and should be reported to the provider.
C. Aspartate aminotransferase 34 units/L (0 to 34 units/L): This value is on the upper limit of normal and generally does not require reporting unless there are other clinical concerns.
D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL): This value is at the upper limit of normal and does not require reporting unless there are additional symptoms or concerns.
Correct Answer is A
Explanation
A. Use the client's left arm to obtain blood samples: This is correct as using the arm on the opposite side of the mastectomy helps avoid additional stress or injury to the affected arm, which can help prevent lymphedema.
B. Keep both arms below the level of the client's heart: This is not recommended as elevating the affected arm can help reduce swelling and promote lymphatic drainage.
C. Limit range-of-motion exercises with the affected arm: This is incorrect as range-of-motion exercises are important to prevent stiffness and promote circulation, which helps reduce the risk of lymphedema.
D. Obtain blood pressure readings using the client's right arm: This is incorrect as obtaining blood pressure on the affected side could increase the risk of lymphedema.
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