A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
Performing the procedure independently
Attending a class given about tracheostomy care
Verbalizing all steps in the procedure
Asking appropriate questions about suctioning
The Correct Answer is A
Performing the procedure independently is the best indicator of the partner's readiness for the client's discharge, as it demonstrates competence and confidence in suctioning. Suctioning is a skill that requires practice and supervision until mastery is achieved. The nurse should observe and evaluate the partner's performance of suctioning and provide feedback and reinforcement as needed.
b) Attending a class given about tracheostomy care is a good action by the partner, but not the best indicator of readiness for the client's discharge. Attending a class can provide information and education about tracheostomy care, but it does not necessarily translate into skill acquisition or application. The nurse should assess the partner's understanding and retention of the information and provide additional teaching or clarification as needed.
c) Verbalizing all steps in the procedure is a good action by the partner, but not the best indicator of readiness for the client's discharge. Verbalizing all steps in the procedure can help the partner remember and follow the correct sequence and technique of suctioning, but it does not necessarily reflect actual performance or ability. The nurse should observe and verify that the partner is doing what they are saying and correct any errors or omissions as needed.
d) Asking appropriate questions about suctioning is a good action by the partner, but not the best indicator of readiness for the client's discharge. Asking appropriate questions about suctioning can show interest and involvement in learning and caring for the client, but it does not necessarily indicate competence or confidence in suctioning. The nurse should answer the partner's questions and provide additional resources or referrals as needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A
Rationale:
A) Administering a nebulized beta-adrenergic:
In the case of an acute asthma exacerbation, administering a nebulized beta-adrenergic agonist (such as albuterol) is the highest priority. These medications act quickly to relax bronchial smooth muscle, dilate airways, and improve airflow. This intervention directly addresses the underlying bronchospasm and helps to alleviate the acute symptoms of asthma.
B) Providing immediate rest for the client:
While rest is important in managing an acute asthma exacerbation, it is not the immediate priority. Addressing the airway obstruction with appropriate medications is crucial for stabilizing the client's condition before focusing on comfort measures such as rest.
C) Positioning the client in high-Fowler's:
Positioning the client in a high-Fowler's position can help improve lung expansion and facilitate breathing. However, this action is secondary to administering medication that can relieve the acute symptoms of bronchoconstriction. The medication should be administered first to rapidly address the exacerbation.
D) Initiating oxygen therapy:
Oxygen therapy might be necessary if the client shows signs of hypoxemia or severe respiratory distress. However, the immediate priority is to address the bronchospasm with a nebulized beta-adrenergic agonist to improve airflow. Once the acute bronchospasm is managed, oxygen therapy can be implemented if needed to support oxygen saturation.
Correct Answer is C
Explanation
A. Administration of a prescribed bronchodilator is typically recommended approximately 30 minutes prior to meals rather than 1 hour. This pharmacological timing helps reduce dyspnea and facilitates easier deglutition and mastication by improving airflow. Using it too early may result in the peak therapeutic effect tapering off before the client finishes the meal.
B. Consuming 3 large meals each day is contraindicated for clients with chronic obstructive pulmonary disease because a distended stomach can exert upward pressure on the diaphragm. This abdominal crowding significantly increases the work of breathing and leads to early satiety or respiratory distress. Clients are instead encouraged to eat 5 to 6 small, frequent, nutrient-dense meals.
C. The nurse should instruct the client to limit water or fluid intake during the actual mealtime to prevent premature gastric distention. Early fullness from fluids reduces the client’s ability to consume essential solid nutrients and calories required to support the increased metabolic demands of labored breathing. Fluids should be consumed between meals to maintain adequate hydration and thin secretions.
D. Reducing protein intake is inappropriate because these clients require high-protein and high-calorie diets to prevent muscle wasting and support the respiratory muscles. The metabolic cost of breathing in chronic obstructive pulmonary disease is significantly elevated, often leading to a state of malnutrition or cachexia. Protein is vital for tissue repair and maintaining the functional integrity of the diaphragm.
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