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 D

Explanation

The first two actions the nurse should take are to obtain a sputum culture and a chest X-ray.
These tests can help diagnose the cause of the client’s symptoms and guide treatment.
Choice A is wrong because administering antibiotics and bronchodilators should only be done after a diagnosis has been made.
Choice B is wrong because airborne precautions and isolation may not be necessary depending on the cause of the client’s symptoms.
Choice C is wrong because cough suppressants and antihistamines may not be appropriate treatments depending on the cause of the client’s symptoms.

A. The client's belief that his needs will be met through education. B. The nurse explains the need for education to the client. C. The client seeking family approval by agreeing to a teaching plan. D. The nurse's empathy about the client having to self-inject.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

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?