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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When administering multiple medications via an NG tube, each medication should be prepared separately by crushing (if appropriate) and diluting it with sterile water. This method helps prevent drug interactions, ensures that medications are adequately dissolved, and minimizes the risk of clogging the tube.
Choice B is wrong because medications should not be combined with the formula in the feeding bag.
Choice C is wrong because the NG tube should be flushed with at least 15 to 30 mL of water before and after drug delivery.
Choice D is wrong because each medication should be administered separately when it is being given at the same time.
Correct Answer is A
Explanation
According to self-efficacy theory, learning develops from multiple sources, including perceptions of one’s past performance, vicarious experiences, performance feedback, affective/physiological states, and social influences.
Choice B is wrong because simply explaining the need for education to the client may not necessarily increase their motivation to learn.
Choice C is wrong because seeking family approval by agreeing to a teaching plan may not necessarily increase the client’s motivation to learn.
Choice D is wrong because the nurse’s empathy about the client having to self-inject may not necessarily increase their motivation to learn.
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