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 A
Explanation
A. Place the client in a negative-pressure airflow room: This is correct as these symptoms are indicative of tuberculosis (TB), which requires airborne precautions. A negative-pressure room helps to prevent the spread of airborne pathogens.
B. Wear a surgical mask when entering the client's room: This is incorrect because a surgical mask does not provide adequate protection against airborne particles; an N95 respirator is necessary for airborne precautions.
C. Have a container for soiled linens outside the client's door: This is incorrect as soiled linens should be handled and disposed of within the room under appropriate infection control protocols, not just placed outside.
D. Remain within 91.4 cm (3 ft) of the client: This is incorrect as maintaining this distance does not prevent the spread of airborne diseases. Proper airborne precautions, including the use of personal protective equipment, are necessary.
Correct Answer is D
Explanation
A. "You should focus on recovering from your cancer right now.": This is incorrect because it dismisses the client's concerns about sexual function and does not address their immediate emotional and psychological needs.
B. "There are other ways to express intimacy besides intercourse.": This is a valid point, but it does not directly address the specific concern about maintaining sexual function, which the client may need to hear for reassurance.
C. "I'm sure any partner will understand that you have no control over this.": This is incorrect because it does not provide specific reassurance about the effects of the surgery on sexual function and can come across as dismissive.
D. "The removal of a single testicle will not prevent you from having an erection.": This is correct as the removal of one testicle does not generally impact the ability to achieve or maintain an erection, and it provides specific reassurance about sexual function.
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