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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Prone with arms raised over the head.
This position involves lying face down with the arms raised over the head. It is not appropriate for thoracentesis because it does not provide easy access to the thoracic cavity, and it may compress the chest, making it difficult for the client to breathe comfortably during the procedure.
B. Sitting, leaning forward over the bedside table.
This is the correct choice. For thoracentesis, the client should be positioned sitting upright and leaning forward over the bedside table or supported by pillows. This position allows better access to the thoracic cavity and facilitates the removal of pleural fluid. Leaning forward also helps to open up the intercostal spaces, making it easier for the healthcare provider to insert the needle into the appropriate space between the ribs.
C. High Fowler's position.
The High Fowler's position involves the client sitting upright with the head of the bed elevated at a 90-degree angle. While this position may be used for other respiratory procedures or for comfort, it is not the optimal position for thoracentesis. It does not provide the same degree of access to the thoracic cavity as the sitting position with forward leaning.
D. Side-lying with knees drawn up to the chest.
This position involves lying on one side with the knees drawn up to the chest. It is not appropriate for thoracentesis because it does not provide access to the thoracic cavity, and it may obstruct the procedure. Additionally, this position may not be comfortable for the client during the procedure.
Correct Answer is B
Explanation
A. Add tap water as needed to the suction control chamber.
This is not the correct action. The suction control chamber of a water-seal chest tube drainage system is typically filled with sterile water to the prescribed level by the healthcare provider during the initial setup. Adding tap water to the suction control chamber can disrupt the balance of the system and affect the prescribed suction level. The nurse should not add tap water without specific instructions from the healthcare provider.
B. Maintain the drainage container below the level of the client's chest.
This is the correct action. In a water-seal chest tube drainage system, it's important to keep the drainage container below the level of the client's chest. This positioning allows gravity to assist in the drainage of air or fluid from the pleural space into the drainage container. It also helps prevent backflow of fluid or air into the chest cavity, ensuring the effectiveness of the drainage system.
C. Empty the collection container every shift.
While it may be necessary to empty the collection container if it becomes full, emptying it every shift is not a set rule. The frequency of emptying the collection container should be based on the volume of drainage and the facility's policy. The nurse should monitor the collection container regularly and empty it when it reaches the appropriate level, typically around half full or as indicated by facility protocol.
D. Clamp the chest tubes if it becomes disconnected.
Clamping the chest tubes if they become disconnected is not recommended. It can lead to tension pneumothorax, a life-threatening condition where air accumulates in the pleural space and compresses the lung. If a chest tube becomes disconnected, the nurse should immediately assess the situation, secure the chest tube connections, and notify the healthcare provider for further management.
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