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 C

Explanation

A. Saving the sputum specimen in a clean container.

While it is important to collect the sputum specimen in a clean, sterile container, simply saving the specimen in a clean container is not sufficient. The nurse needs to actively collect the sputum specimen from the client using proper technique to ensure that it is not contaminated and is suitable for laboratory analysis.

B. Collecting the sputum specimen after a meal.

Collecting a sputum specimen after a meal is not recommended, as it can increase the likelihood of contamination with food particles. It's preferable to collect the specimen before meals or at least 1-2 hours after eating to minimize the risk of contamination and ensure the integrity of the specimen.

C. Rinse the client's mouth before collecting the specimen.

When obtaining a sputum specimen from a client, it's important for the nurse to plan to rinse the client's mouth before collecting the specimen. Rinsing the mouth with water helps to clear any food particles or debris from the oral cavity, ensuring that the sputum sample collected is not contaminated with saliva or food particles. This improves the quality and accuracy of the specimen for laboratory analysis.

D. Obtaining the specimen from the client in the evening.

The timing of specimen collection is not necessarily restricted to the evening. The timing may vary depending on the client's condition and the healthcare provider's orders. It's important to follow the healthcare provider's instructions regarding the timing of specimen collection, which may be based on factors such as the client's symptoms and the diagnostic requirements.

A. The patient's Spo2 is 97% on 2L NC B. The patient appears comfortable C. The patient is coughing up copious white sputum D. The patient is able to move out of bed without difficulty

Correct Answer is A

Explanation

A. The patient's Spo2 is 97% on 2L NC:

This assessment finding indicates that the patient's oxygen saturation level (SpO2) is 97% while receiving 2 liters per minute of oxygen via nasal cannula. Oxygen saturation is a measure of the percentage of hemoglobin saturated with oxygen in the blood. A SpO2 level of 97% suggests adequate oxygenation, which is essential for effective gas exchange. Therefore, if the patient's SpO2 is within the target range on the prescribed oxygen therapy, it indicates that the interventions aimed at improving gas exchange have been effective.

B. The patient appears comfortable:

While patient comfort is important, it is not a direct indicator of effective gas exchange. A patient may appear comfortable for various reasons, such as pain relief, proper positioning, or emotional support, but this does not necessarily reflect improved gas exchange. Therefore, while comfort is an important aspect of nursing care, it is not specifically indicative of the effectiveness of interventions for impaired gas exchange.

C. The patient is coughing up copious white sputum:

The presence of copious white sputum does not directly indicate improved gas exchange. White sputum may suggest various conditions, such as respiratory tract infections or inflammation, but it does not provide direct information about gas exchange efficiency. Effective gas exchange involves the exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, which cannot be assessed solely based on sputum production.

D. The patient is able to move out of bed without difficulty:

The ability to move out of bed without difficulty may indicate improved overall physical function or mobility, but it does not specifically reflect improved gas exchange. Gas exchange primarily involves the transfer of oxygen from the alveoli into the bloodstream and the removal of carbon dioxide from the bloodstream into the alveoli for exhalation. While improved gas exchange may lead to enhanced physical endurance and reduced dyspnea, the ability to move out of bed without difficulty is not a direct measure of gas exchange efficiency.

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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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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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