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 C
Explanation
A. Perform immediate defibrillation: This is necessary for ventricular tachycardia with a pulse if it is unstable, but first, assess the client’s condition.
B. Provide pulmonary ventilation: This may be required depending on the client's breathing status but is secondary to assessing the pulse.
C. Determine palpable pulse: This is the priority action. Determining whether the client has a pulse helps guide the next steps—if the client has a pulse but is symptomatic, treatment will differ from if the client is pulseless.
D. Begin chest compressions: This is done if the client is pulseless. If there is a pulse, other interventions are needed first.
Correct Answer is C
Explanation
A. The medication reduces the rate at which the kidneys filter waste: This is incorrect as oxybutynin does not affect kidney function or the rate at which kidneys filter waste.
B. The medication decreases the sensitivity of the urethral sphincter: This is incorrect because oxybutynin primarily affects bladder muscle contraction, not the sensitivity of the urethral sphincter.
C. The medication prevents the bladder muscles from involuntarily contracting: This is correct as oxybutynin is an anticholinergic medication that reduces involuntary bladder contractions, leading to less frequent urination.
D. The medication blocks the nervous system impulse to produce urine: This is incorrect because oxybutynin works by blocking the action of acetylcholine in the bladder, not by blocking impulses to produce urine.
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