A client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic, with the tracheostomy tube lying on his chest. Which action by the nurse takes priority?
a. Auscultate breath sounds bilaterally.
b. Ventilate with a resuscitation bag and mask.
c. Call a code or the Rapid Response Team.
d. Insert a new obturator into the neck.
B
Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. First, ventilate the client using a manual resuscitation bag and facemask while another nurse calls for help. Although auscultation of breath sounds is important, the client's airway must be opened and ventilation started. Ventilation should begin while another nurse calls the code. Reinsertion of a fresh tracheostomy tube will require the physician's intervention.
You might also like to view...
A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.)
a. Assessing distal circulation to the operative arm after positioning b. Keeping the client warm during the operative procedure c. Padding the client's shoulder and arm on the operating table d. Preparing to suction the client's airway if the client vomits e. Speaking in a low, quiet voice as anesthesia is administered
A nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which of the following, if exhibited in the client, would indicate hyperglycemia and warrant physician notification?
A) Polyuria B) Diaphoresis C) Hypertension D) Increased pulse rate
A client with a history of schizophrenia is diagnosed with a urinary tract infection. What is probably the most significant barrier this patient faces?
1) Chronic urinary incontinence 2) Stigma associated with mental illness 3) Risk for recurring infections 4) Auditory hallucinations ("hearing things")
Which diagnostic tests should the nurse include in the plan of care for a pediatric client who is at risk for short stature? Select all that apply
1. Thyroid function studies 2. Adrenocorticotropic hormone (ACTH) and cortisol levels 3. Complete blood count 4. Blood culture 5. Urine creatinine