A home health nurse is providing education to a client discharged with a tracheostomy. Which statement by the client demonstrates teaching has been effective?
“My spouse should always take care of my tracheostomy. I should not do it myself.”.
“I am the only one who needs to know how to suction my tracheostomy at home.”.
“I can use my saline for longer than 24 hours if I boil it.”.
“I can use clean instead of sterile technique to suction my tracheostomy.”.
The Correct Answer is D
“I can use clean instead of sterile technique to suction my tracheostomy.” This statement demonstrates that the client understands how to care for their tracheostomy at home. According to the American Thoracic Society, clean technique can be used for suctioning at home, as long as the equipment is cleaned and stored properly.
Choice A is wrong because the client should be able to take care of their own tracheostomy as much as possible, with the help of a caregiver if needed. This promotes independence and self-care.
Choice B is wrong because the client should not be the only one who knows how to suction their tracheostomy at home. They should have at least one backup person who can assist them in case of an emergency or if they are unable to do it themselves.
Choice C is wrong because the client should not use saline for longer than 24 hours, even if they boil it.
Saline can become contaminated with bacteria and cause infection. The client should use fresh saline every time they suction their tracheostomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The popliteal artery is a major blood vessel that runs behind the knee and supplies blood to the lower leg. Sitting with knees crossed can compress this artery and reduce blood flow to the leg.
This can cause numbness, tingling, or pain in the leg. It can also increase the risk of blood clots or varicose veins.
Choice A is wrong because sitting with knees crossed does not decrease the risk of skin breakdown behind the knee. In fact, it may increase the risk by causing friction or pressure on the skin.
Choice B is wrong because sitting with knees crossed does not eliminate the pain of arthritis in the lower legs.
Arthritis is a joint inflammation that causes pain, stiffness, and swelling. Sitting with knees crossed can worsen these symptoms by putting more stress on the knee joints.
Choice D is wrong because sitting with knees crossed does not avoid irritation of the knee joints.
On the contrary, it can cause irritation by overstretching the knee ligaments and muscles
Correct Answer is A
Explanation
Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.
This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.
The nurse should intervene and use a manual BP cuff with a stethoscope instead.
Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.
Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.
The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.
Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.
Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.
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