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 ["A","B","D"]

Explanation

A. Prolonged standing or sitting can worsen venous insufficiency and increase the risk of blood pooling in the legs. Encouraging the client to move around and avoid prolonged periods of immobility can help improve circulation.

B. Compression stockings help improve blood flow by applying pressure to the legs, reducing swelling and preventing blood from pooling. The client should be instructed to continue wearing them as prescribed by their healthcare provider.

C.Crossing the legs can impede blood flow and should be avoided altogether.

D. Sitting for extended periods can also contribute to blood pooling. Using a recliner allows the client to elevate their legs, promoting better circulation and reducing the risk of complications. The nurse should recommend using a recliner when sitting for long periods of time.

E.Elevating legs during sleep is generally advised to reduce venous pressure.

A. Bends from the waist to pick trash off the floor. B. Widens stance while working near the sink. C. Locks knees while preparing food on the counter. D. Brings a heavy can close to body before lifting. E. Leans forward to pull a pan from a high shelf

Correct Answer is ["B","D"]

Explanation

A) Incorrect- This behavior is not safe for maintaining balance. Bending from the waist can increase the risk of falling. Clients should bend at the knees and use proper body mechanics to pick up objects from the floor.
B) Correct- Widening the stance provides a broader base of support, which can help improve balance and stability while working near the sink. This is a safe behavior to maintain balance.
C) Incorrect- Locking the knees while standing can lead to instability and decreased balance. It is recommended to keep the knees slightly flexed to maintain better balance.
D) Correct- Bringing a heavy object close to the body before lifting minimizes strain on the back and helps maintain balance. This is a safe behavior when lifting objects.
E) Incorrect- Leaning forward to pull an object from a high shelf can disrupt the center of balance and increase the risk of falling. It's important to use a step stool or ask for assistance when reaching for items on high shelves.

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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

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