You are working on a medical-surgical unit caring for a client with a new tracheostomy placed less than 48 hr ago. While

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You are working on a medical-surgical unit caring for a client with a new tracheostomy placed less than 48 hr ago. While suctioning the client's airway, you notice a small amount of blood in his secretions. You measure his vital signs. His blood pressure is 130/85 mm Hg, his heart rate is 65/min, his respiratory rate is 20/min, and his oxygen saturation is 94%. The client reports a pain level of 2 on a 0 to 10 scale and was given pain medication 1 hour ago. He is alert, oriented, and communicating by writing on a pad of paper at the bedside
Which of the following describes the blood in the secretions? A An indication that the client might have to return to surgery B A sign that the client might be developing an infection с An expected finding for this client at this time Submit
Your client activates his call light. When you arrive, he is obviously distressed and pointing to his tracheostomy. You see frank blood oozing from the stoma. While determining that the client's airway is patent, you alert another nurse to notify the surgeon immediately.
Which of the following is the priority action for this client? A Measure vital signs. B Elevate the head of the bed to 90 degrees. C Administer a prescribed PRN antianxiety medication.
The surgeon arrives to assess the client and instructs you to prepare him to return to the surgical suite. He explains the situation to the client and leaves to set up the surgery.
Which of the following is the appropriate nursing action to maintain airway patency prior to arranging transportation to the surgical suite ? A Suction the client's airway. B Apply sterile gauze around the tracheostomy site. c Ventilate the client with a manual-resuscitation bag
Despite preoperative sedation, your client appears extremely anxious. He writes a question for you on his pad of paper: "Does this bleeding mean I won't be able to have a tube in my neck after all?"
Which of the following is an appropriate nursing response? "Right now we're going to get you to surgery so that your doctor can stop this bleeding. Then we'll get you comfortable again and see what your options are." B "Let's focus on what a tracheostomy is and why you need it. Remember what we went over before you had the tube inserted." C "Why do you think this bleeding will mean you cannot have a tracheostomy at all?"
The client is agreeable to your action plan and soon after is transported to the surgical suite. He returns to your care few hours later after the surgeon cauterizes a superficial blood vessel. You have successfully managed the immediate needs of your client.