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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is important to prevent urine from flowing back into the bladder, which can cause infection 1.
Choice A is incorrect because the catheter should be secured to the outer side of the thigh, not taped to the lower abdomen 2.
Choice B is incorrect because attaching the drainage bag to the side rails of the bed can cause it to be above the level of the bladder.
Choice C is incorrect because it is important to empty the drainage bag regularly, not just when it is three-quarters full.
Correct Answer is D
Explanation
According to the Centers for Disease Control and Prevention (CDC), tuberculosis (TB) infection control plan is part of a general infection control program designed to ensure prompt detection of infectious TB patients, airborne precautions, and treatment of people who have suspected or confirmed TB disease.
Choice A, Contact precautions, are not necessary for TB patients as TB is not spread through contact.
Choice B, Protective precautions, are used to protect immunocompromised patients from infections and are not necessary for TB patients.
Choice C, Droplet precautions, are used for diseases that are spread through large respiratory droplets and are not necessary for TB patients as TB is spread through airborne droplet nuclei.
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