A nurse is assisting with the care of a client who is 2 days postoperative following the creation of a tracheostomy. Which of the following actions should the nurse plan to take?

Place the client in left Sims' position.

Provide humidified air.

Clean the tracheostomy stoma with povidone-iodine.

Use clean technique when providing tracheostomy suctioning.

Answer and Explanation

The Correct Answer is B

A. Place the client in left Sims' position.

Left Sims' position is a lateral position used primarily for rectal examinations or procedures. It involves lying on the left side with the lower arm positioned behind the body and the upper knee flexed. This position is not indicated for a client post-tracheostomy. It does not provide any specific benefit for tracheostomy care and may not be comfortable or appropriate for a client recovering from tracheostomy surgery.

B. Provide humidified air.

Providing humidified air is crucial for clients post-tracheostomy to maintain moisture in the airway and prevent drying of secretions. Tracheostomy bypasses the upper airway's natural humidification mechanism, which can lead to drying of the mucous membranes and increased risk of complications such as mucus plugging and infection. Humidified air helps keep the secretions moist, facilitates their removal, promotes airway clearance, and reduces the risk of complications.

C. Clean the tracheostomy stoma with povidone-iodine.

While povidone-iodine is an antiseptic solution commonly used for skin preparation before invasive procedures, it is not typically used to clean the tracheostomy stoma, especially in the immediate postoperative period. Cleaning the stoma should be performed using sterile technique and appropriate solutions as directed by the healthcare provider. Using povidone-iodine may not be suitable for cleaning the tracheostomy stoma and could potentially irritate the area or introduce contaminants.

D. Use clean technique when providing tracheostomy suctioning.

Tracheostomy suctioning should always be performed using sterile technique to minimize the risk of introducing pathogens into the lower airway and causing infection. Clean technique, which involves washing hands and using clean gloves, is not appropriate for tracheostomy care, particularly in the immediate postoperative period when the risk of infection is higher. Sterile technique involves the use of sterile gloves, sterile suction catheters, and maintaining a sterile field to ensure the safety and cleanliness of the procedure.

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Correct Answer is B

Explanation

First, we need to find out how many milligrams (mg) are in 1 milliliter (mL) of the available diphenhydramine solution:

12.5 mg/5 mL

To find out how many milligrams are in 1 mL, we divide the total milligrams by the total milliliters:

12.5 mg ÷ 5 mL = 2.5 mg/mL

Now that we know the concentration of diphenhydramine is 2.5 mg/mL, we can calculate the dose needed for the order of 25 mg:

25 mg ÷ 2.5 mg/mL = 10 mL

A. 1 day after injection with a 10-mm area of redness and swelling B. 2 days after injection with a 5-mm area of redness and swelling C. 4 days after injection with a 3-mm area of redness and swelling D. 5 days after injection with a 2-mm area of redness and swelling

Correct Answer is A

Explanation

A. 1 day after injection with a 10-mm area of redness and swelling:

This may suggest a positive reading, but induration size is the primary criterion for interpretation, not just redness and swelling.

B. 2 days after injection with a 5-mm area of redness and swelling:

Similar to option A, a 5-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. Again, without information on the size of the induration, we cannot determine if this reading is positive.

C. 4 days after injection with a 3-mm area of redness and swelling:

Once more, a 3-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. As with the previous options, the size of the induration is the critical factor for interpretation.

D. 5 days after injection with a 2-mm area of redness and swelling:

As with the other options, a 2-mm area of redness and swelling alone does not definitively indicate a positive TB skin test. The presence and size of induration are essential for accurate interpretation.

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A nurse is assisting with the care of a client who is 2 days postoperative following the creation of a tracheostomy. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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