The nurse is caring for a client with a new tracheostomy. Which action is most important to include in the client’s plan of care?

Change the tracheostomy ties every 48 hours.

Suction the tracheostomy every 2 hours routinely.

Assess airway patency every shift.

Clean the inner cannula with hydrogen peroxide daily.

Answer and Explanation

The Correct Answer is C

Choice A reason: Changing tracheostomy ties every 48 hours maintains hygiene but is less critical than airway patency. Ties secure the tube, but obstruction from mucus or dislodgement risks respiratory failure. Regular patency checks ensure airflow, addressing the primary physiological need for oxygenation in tracheostomy care.

Choice B reason: Routine suctioning every 2 hours is unnecessary unless secretions obstruct the airway. Over-suctioning risks mucosal trauma or hypoxia. Assessing patency ensures the airway remains clear, guiding suctioning as needed, prioritizing respiratory function in tracheostomy clients over arbitrary suction schedules.

Choice C reason: Assessing airway patency every shift is critical, as tracheostomy tubes risk obstruction from mucus or dislodgement, causing respiratory distress. Regular checks confirm airflow, preventing hypoxia, addressing the physiological priority of oxygenation. This ensures timely intervention, maintaining airway integrity in clients with artificial airways.

Choice D reason: Cleaning the inner cannula daily prevents infection but is secondary to airway patency. Obstruction from secretions or tube displacement causes immediate respiratory failure. Patency assessment ensures airflow, guiding cleaning as needed, making it more urgent than routine cannula maintenance in tracheostomy care.

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Correct Answer is B

Explanation

Choice A reason: Positioning the sterile field at hip level maintains sterility but is not specific to uncircumcised clients. Cleaning the meatus before retracting the foreskin prevents infection by removing bacteria first. This is secondary, per infection control and catheterization procedure standards in nursing practice.

Choice B reason: Cleaning the meatus before retracting the foreskin removes bacteria, reducing infection risk in uncircumcised clients. This sequence ensures sterility before exposing sensitive areas, critical for preventing urinary tract infections, per evidence-based catheterization and infection control protocols in urological nursing care.

Choice C reason: Wiping the meatus in backward strokes is incorrect, as circular strokes from meatus outward are standard to avoid contamination. Cleaning before retracting the foreskin is critical for infection prevention. This violates sterile technique, per catheterization and infection control standards in nursing.

Choice D reason: Advancing the catheter before inflating the balloon is standard but not specific to uncircumcised clients. Cleaning the meatus first addresses foreskin-related infection risks. Balloon inflation timing is universal, per indwelling catheter insertion and urological care protocols in nursing practice.

A. Protein and albumin. B. Complete blood count (CBC). C. BUN and creatinine. D. Electrolytes.

Correct Answer is B

Explanation

Choice A reason: Protein and albumin reflect nutritional or liver status but are unaffected by enoxaparin, a low-molecular-weight heparin inhibiting factor Xa. These do not monitor anticoagulation effects or complications like bleeding. CBC is critical, as enoxaparin increases bleeding risk, requiring platelet and hemoglobin monitoring to detect serious hematological issues.

Choice B reason: Enoxaparin, an anticoagulant, heightens bleeding risk and can cause thrombocytopenia. Monitoring CBC, especially platelets and hemoglobin, detects heparin-induced thrombocytopenia (HIT) or hemorrhage. This ensures early identification of complications, allowing timely intervention to prevent severe bleeding or thrombosis, making CBC the most critical test for safe administration.

Choice C reason: BUN and creatinine assess renal function, relevant for renally cleared drugs, but enoxaparin is primarily liver-metabolized. Renal monitoring is secondary unless severe impairment exists. CBC is more urgent, as enoxaparin’s anticoagulant effect increases bleeding risk, necessitating hematological surveillance to prevent life-threatening complications.

Choice D reason: Electrolytes like potassium or sodium are not directly affected by enoxaparin’s action on the coagulation cascade. Imbalances may occur in critical illness but are not primary concerns. CBC monitoring for bleeding or thrombocytopenia is critical, as enoxaparin’s anti-Xa activity poses hematological risks requiring immediate attention.

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The nurse is caring for a client with a new tracheostomy. Which action is most important to include in the client’s plan of care?

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