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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Apply a heat pack to the client's lower abdomen: This is incorrect as applying heat can worsen inflammation and increase the risk of rupture; ice packs are generally used instead.
B. Place the client in semi-Fowler's position: This is correct as the semi-Fowler's position helps reduce pain and pressure on the abdomen and can improve comfort before surgery.
C. Give the client a clear liquid diet: This is incorrect as a clear liquid diet is not appropriate for a client with acute appendicitis who may require NPO (nothing by mouth) status prior to surgery.
D. Administer an enema to the client: This is incorrect as enemas are contraindicated in acute appendicitis due to the risk of perforation and worsening of the condition.

A. Obtain vital signs every 5 min. B. Place the client in high-Fowler's position. C. Perform gastric lavage. D. Prepare to administer anticoagulants. E. Initiate a second peripheral IV. F. Apply oxygen.

Correct Answer is ["A","E","F"]

Explanation

A. Obtain vital signs every 5 min.

Rationale: The client's vital signs indicate hypotension (blood pressure 88/54 mm Hg) and tachycardia (heart rate 104/min). Frequent monitoring of vital signs is essential to assess changes in the client's condition and guide further interventions.

E. Initiate a second peripheral IV.

Rationale: Given the client's low urine output (110 mL over 6 hours) and signs of possible hypovolemia or fluid imbalance, establishing an additional IV line can facilitate the administration of fluids and medications more effectively.

F. Apply oxygen.

Rationale: The client's oxygen saturation is slightly decreased at 96% on room air. Applying supplemental oxygen can help improve oxygenation and alleviate symptoms related to decreased oxygen levels.

Not Recommended Actions:

B. Place the client in high-Fowler's position: This position might not be appropriate for a client with chest pain and potential hypovolemia, as it could exacerbate hypotension.

C. Perform gastric lavage: The output from the nasogastric tube (800 mL sanguineous) does not indicate a need for gastric lavage unless there is a specific reason to suspect gastrointestinal bleeding that requires immediate intervention.

D. Prepare to administer anticoagulants: There is no indication of thromboembolism or need for anticoagulants based on the provided information. The focus should be on addressing hypotension and fluid imbalance.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client who has acute appendicitis for surgery. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The nurse is continuing to assist in the care of the client. Exhibits After reviewing the client's electronic medical record, which of the following actions should the nurse recommend to take? Select the 3 actions the nurse should recommend to take.

Correct Answer is ["A","E","F"]

Explanation

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