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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Correct Answer is B

Explanation

This is because during the alarm reaction stage of general adaptation syndrome, which is also known as the fight-or-flight response, the sympathetic nervous system is activated by the sudden release of hormones.
This hormone release causes physical symptoms such as dilated pupils.
Choice A is wrong because depression is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
Choice C is wrong because bradycardia, or a slow heart rate, is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
Instead, an increase in heart rate is a common physical sign during this stage.
Choice D is wrong because physical exhaustion is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
Physical exhaustion occurs during the final stage of general adaptation syndrome, which is known as the exhaustion stage.

A. "You are required to sign advance directives prior to having surgery." B. "Your provider must sign the advance directives before surgery." C. "You will receive written information about advance directives prior to signing." D. "Your partner must be present when you sign the advance directives."

Correct Answer is C

Explanation

This statement indicates that the client will be provided with information about advance directives before making a decision.
Advance directives are legal documents that allow individuals to communicate their wishes for medical treatment in the event that they are unable to make decisions for themselves.
Choice A is wrong because signing advance directives is not a requirement for undergoing surgery.
Choice B is wrong because the provider does not need to sign the advance directives.
Choice D is wrong because the presence of a partner is not required when signing advance directives.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

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?