Portage Learning Pathophysiology NURS 231 BIOD 331 Module 1-10 Final Exam with Questions and Answers

Portage Learning Pathophysiology NURS 231 BIOD 331 Module 1-10 Final Exam with Questions and Answers The nurse coming on shift prepares to perform an initial assessment of a client receiving sedation and mechanical ventilation through a tracheostomy. Which are priorities for the nurse to carry out? (Select all that apply.) a) Provide routine tracheostomy and mouth care. b) Assess the client's color and respirations. c) Ask visitors to leave the room. d) Auscultate for bilateral breath sounds. e) Confirm alarms and ventilator settings. f) Ensure that the tube is in proper position. ANSWER b) Assess the client's color and respirations. d) Auscultate for bilateral breath sounds. e) Confirm alarms and ventilator settings. f) Ensure that the tube is in proper position. *Initial priorities when assessing is to assess airway and breathing. Alarm settings should be confirmed each shift, more frequently if necessary. Markings on the endotracheal tube should be compared to previous records to ensure the tube remains in appropriate position. Auscultating for equal bilateral breath sounds assists in confirming that the tube is in the proper position above the carina. *It is not necessary to ask visitors to leave. Having visitors remain with the client may promote comfort and prevent confusion.Routine tracheostomy care is an intervention performed according to schedule and as needed, and is not necessarily part of an initial assessment.