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 A

Explanation

Thirst is a common symptom of hyperglycemia, or high blood sugar, in clients with diabetes mellitus.
Choice B is wrong because confusion can be a symptom of both hyperglycemia and hypoglycemia (low blood sugar).
Choice C is wrong because shakiness is more commonly associated with hypoglycemia.
Choice D is wrong because cool skin is not a common symptom of hyperglycemia.

A. Expose the client's abdomen to look for changes in appearance. B. Determine areas of resonance across the abdomen using a systematic approach. C. Use the diaphragm of a stethoscope to listen for bowel sounds. D. Perform abdominal palpation by pressing gently with the finger pads.

Correct Answer is A

Explanation

After postoperative surgery, chances of infections are very high also discharges, color changes, etc.
So it is important to expose the client’s abdomen to look for changes in appearance.

Choice B is not the answer because determining areas of resonance across the abdomen using a systematic approach is not the first action that should be taken 1.
Choice C is not the answer because using the diaphragm of a stethoscope to listen for bowel sounds is not the first action that should be taken 1.
Choice D is not the answer because performing abdominal palpation by pressing gently with the finger pads is not the first action that should be taken 1.

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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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Explanation

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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?