The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Call for an assistant.

Respond to the code.

Finish the procedure.

Close the room door.

Answer and Explanation

The Correct Answer is A

Tracheostomy care is done to keep the trach tube clean and prevent infections. It involves suctioning and cleaning parts of the tube and the skin around the stoma. A code blue is a hospital emergency code that indicates a life-threatening situation, such as cardiac or respiratory arrest. It requires immediate attention from trained personnel.

According to the American Association of Critical-Care Nurses (AACN), the nurse should take the following action in this scenario:

Call for an assistant to stay with the client who is receiving tracheostomy care and continue the procedure.
Respond to the code blue and assist with resuscitation efforts for the other client.
Return to the client who is receiving tracheostomy care as soon as possible and complete the procedure.

Therefore, the correct answer is a. Call for an assistant.

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Correct Answer is C

Explanation

A) Incorrect - Developing and implementing new screening protocols does not directly indicate the effectiveness of a primary prevention program. It might indicate improved detection, but not necessarily prevention.
B) Incorrect - This outcome relates to secondary prevention (rehabilitation after disease complications) rather than primary prevention.
C) Correct- An improvement in average client scores on risk factor knowledge tests suggests that the primary prevention program has successfully educated clients about behaviors and practices that can help prevent sexually transmitted diseases. This improvement indicates that clients have a better understanding of the risks and protective measures, which is a key indicator of program effectiveness.
D) Incorrect - Diagnosing clients early in their disease process is an outcome of early detection (secondary prevention), not primary prevention.

A. Administer IV opioids as needed for pain. B. Teach how to use incentive spirometry. C. Monitor for confusion and restlessness. D. Observe for signs of increased bleeding.

Correct Answer is D

Explanation

A.While pain management is important, it is not the most critical intervention compared to monitoring for bleeding, which can be life-threatening.

B.Teaching the client how to use incentive spirometry is important for improving lung function and preventing complications like atelectasis. However, in the context of a pulmonary embolism (PE), the immediate priority is to monitor for signs of increased bleeding due to the anticoagulant or thrombolytic therapy often used to treat PE. This is crucial to prevent potentially life-threatening complications.

C.Confusion and restlessness could indicate hypoxia, which is important to monitor in a PE patient. However, the immediate risk of bleeding due to anticoagulation therapy takes precedence.

D.Patients with a pulmonary embolism are typically treated with thrombolytic or anticoagulant therapy to prevent further clot formation and to help dissolve the existing clot. Anticoagulants significantly increase the risk of bleeding, making it crucial to monitor for signs of increased bleeding as a priority in the plan of care.

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The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?

Correct Answer is C

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Correct Answer is D

Explanation

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