A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube
Which of the following does the seasoned nurse do first? A) Call for the registered nurse to reinsert the tube.
B) Place a dilator in the stoma to maintain the opening.
C) Cover the tracheostomy site with a sterile gauze to prevent infection.
D) Call for an ambulance and transfer the client to the emergency department.
B
Feedback:
If the tracheostomy tube becomes dislodged, a dilator is initially placed to hold the edges of the stoma apart until a physician is able to reinsert the tube. A tracheal tube must never be forced back into place. Covering the tracheostomy site with gauze can obstruct the stoma, decreasing ventilation. If needed, an ambulance may be called to transport the client to the emergency department but not until the airway is stabilized.
You might also like to view...
A patient must be transferred from one hospital to another due to lack resources at the sending hospital needed by the patient
Which of the following conditions would incline the transport team of the hospital to choose ground transport as opposed to air? Select all that apply. A) Heavy rainfall is in the area. B) The hospitals are 20 miles apart. C) The patient needs a time-sensitive intervention. D) Traffic on the ground is minimal.
Which of the following medications is prescribed to decrease cerebral vasospasm?
a. Phenytoin (Dilantin) c. Nimodipine (Nimotop) b. Phenobarbital d. Vecuronium (Norcuron)
A patient being medicated with haloperidol for over 4 weeks has started to display symptoms of involuntary movements of the mouth that resemble chewing. Of the following extrapyramidal adverse reactions, the client is showing signs of:
A. Dystonia. B. Akathisia. C. Drug-induced Parkinsonism. D. Tardive dyskinesia.
A 40-year-old woman with gray, runny vaginal discharge that has a foul, fishy odor has been told that she most likely has vaginosis. Which of the following phenomena most likely contributed to her present condition?
A) Unprotected sex with a new partner who is a carrier of the relevant bacteria. B) Autoinoculation from a cold sore, wart, or oral fungal infection. C) A sharp reduction in the number of lactobacilli in the client's vaginal flora. D) Proliferation of sexually transmitted protozoa.