A nurse is caring for a client who has a tracheostomy.

Which of the following actions should the nurse take?

Secure the tracheostomy ties to allow one finger to fit snugly underneath.

Cleanse the skin around the stoma with normal saline.

Soak the outer cannula in warm, soapy tap water.

Use a cotton tip applicator to clean inside the inner cannula.

Answer and Explanation

The Correct Answer is A

Secure the tracheostomy ties to allow one finger to fit snugly underneath. This is important to ensure that the tracheostomy tube is secure and in place.

Choice B is wrong because normal saline is not typically used to cleanse the skin around the stoma.

Choice C is wrong because soaking the outer cannula in warm, soapy tap water is not a recommended method of cleaning.

Choice D is wrong because a cotton tip applicator should not be used to clean inside the inner cannula.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A nurse should apply a bath blanket between the client and a cooling blanket when caring for a client who has a high fever.
This can help regulate the temperature of the environment and make it more comfortable for the patient.
Choice B is wrong because placing ice packs on the client’s neck and behind the knees is not recommended as it can cause further problems.
Choice C is wrong because giving the client a sponge bath using an alcohol-water solution is not recommended.
Choice D is wrong because covering the client with heavy blankets after the shivering subsides is not recommended as it can increase body temperature.

A. Showing a client how to use an incentive spirometer prior to surgery. B. Assisting with ambulation for a client who has a pulmonary infection. C. Irrigating a client's infected surgical wound. D. Inserting a glycerin suppository for a client who is constipated.

Correct Answer is B

Explanation

Assisting with ambulation for a client who has a pulmonary infection.
Assistive personnel can perform basic nursing care functions such as assisting patients with mobility.

Choice A is wrong because showing a client how to use an incentive spirometer prior to surgery requires more specialized knowledge and training.
Choice C is wrong because irrigating a client’s infected surgical wound is a more complex medical procedure that should be performed by a licensed nurse.
Choice D is wrong because inserting a glycerin suppository for a client who is constipated is also a more complex medical procedure that should be performed by a licensed nurse.

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A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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A nurse is caring for a client who has a tracheostomy.

Which of the following actions should the nurse take?