Which nursing diagnosis is the priority when caring for a patient with a traumatic brain injury who had a tracheostomy placed?
A) Risk for skin breakdown
B) Impaired gas exchange
C) Ineffective airway clearance
D) Risk for infection

Question

Quizplus · Accepted Answer

Patients with tracheotomies rely on the tracheostomy to provide a stable open airway.The nurse is most concerned about a dementia patient who is extubating himself unknowingly.The nurse is also concerned that the patient would not be able to cough up his own secretions and could occlude the tracheostomy,putting him at risk for Ineffective airway clearance.Nursing priorities are airway,breathing,and circulation.Frequently occurring nursing diagnoses should be addressed before "Risk" diagnoses.Skin breakdown and infection are not immediately life threatening.

Which Nursing Diagnosis Is the Priority When Caring for a Patient