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 C
Explanation
The Weber test is a screening test for hearing performed with a tuning fork that can detect unilateral conductive hearing loss and unilateral sensorineural hearing loss.
To perform Weber’s test, strike the fork against your knee or elbow, then place the base of the fork in the midline, high on the patient’s forehead.
Choice A is wrong because delivering a series of high-pitched sounds at random intervals is not part of Weber’s test.
Choice B is wrong because holding an activated tuning fork against the client’s mastoid process is part of Rinne’s test, not Weber’s test.
Choice D is wrong because whispering a series of words softly into one ear is not part of Weber’s test.
Correct Answer is B
Explanation
A nurse can delegate the task of performing a simple dressing change to an assistive personnel.
Delegation is an essential nursing skill that allows a qualified healthcare worker, like an RN, to transfer routine and low-risk duties to nursing assistive personnel.
This frees up the RN’s time to address more pressing matters, including critical patients and tasks.
Choice A is wrong because changing IV tubing is not a task that can be delegated to assistive personnel.
Choice C is wrong because inserting an NG tube is not a task that can be delegated to assistive personnel.
Choice D is wrong because evaluating the healing of an incision is not a task that can be delegated to assistive personnel.
These tasks require the expertise and training of a licensed nurse.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today