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
“Potassium 5.8 mEq/L” should be reported to the provider because it is higher than the normal range for potassium levels in the blood.
Normal potassium levels range from.6 to 5.2 millimoles per liter (mmol/L)1.
Choices B, C, and D are incorrect because sodium levels of 140 mEq/L, and magnesium levels of.9 mEq/L and calcium levels of 9.6 mg/dL are all within normal ranges and do not need to be reported to the provider.
Correct Answer is C
Explanation
“This test will provide information about the function of your liver.” An alanine aminotransferase (ALT) test measures the level of ALT in the blood, which is an enzyme found primarily in the liver.
Elevated levels of ALT can indicate liver damage or disease.
Choice A, “This test will indicate if you are at risk for developing blood clots,” is not correct as an ALT test does not provide information about blood clot risk.
Choice B, “This test will determine if your heart is performing properly,” is not correct as an ALT test does not provide information about heart function.
Choice D, “This test is used to check how your kidneys are working,” is not correct as an ALT test does not provide information about kidney function.
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