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

The nurse’s entry “New dressing applied as prescribed; no drainage on old dressing” demonstrates correct documentation because it includes specific details about the wound and the dressing change.
Choice A is wrong because it does not provide specific details about the wound or the dressing change.
Choice C is wrong because it includes subjective language (“seems” and “does not appear”) rather than objective observations.
Choice D is wrong because it only documents medication administration and does not provide any information about the wound or the dressing change.

A. "I will keep my legs crossed while sitting." B. "I will perform leg exercises once every 4 hours while I am awake." C. "I should limit the time that I spend sitting in a chair." D. "I should massage my legs when they hurt.".

Correct Answer is C

Explanation

“I should limit the time that I spend sitting in a chair.” This is important because sitting for long periods of time can increase the risk of thrombus formation.
Choice A is wrong because crossing the legs while sitting can impede blood flow and increase the risk of thrombus formation.
Choice B is wrong because leg exercises should be performed more frequently than once every 4 hours while awake.
Choice D is wrong because massaging the legs when they hurt can dislodge a thrombus and cause it to travel to other parts of the body.

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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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A nurse is caring for a client who has a tracheostomy.

Which of the following actions should the nurse take?