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.
Use a cotton tip applicator to clean inside the inner cannula.
Cleanse the skin around the stoma with normal saline.
Soak the outer cannula in warm, soapy tap water.
The Correct Answer is A
When caring for a client who has a tracheostomy, the nurse should secure the tracheostomy ties to allow one finger to fit snugly underneath. This helps ensure that the tracheostomy tube is secure and prevents accidental dislodgement.
b) A cotton tip applicator should not be used to clean inside the inner cannula as it can leave fibers behind
and increase the risk of infection.
c) The skin around the stoma should be cleansed with sterile saline, not normal saline, to reduce the risk of infection.
d) The outer cannula should not be soaked in warm, soapy tap water as this can introduce bacteria and increase the risk of infection.
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Related Questions
Correct Answer is D
Explanation
The nurse should plan to use the client's telephone number to confirm their identity. This is because the telephone number is a unique identifier that is directly associated with the client and can be easily verified. By comparing the client's telephone number with the information on the medication administration record or electronic health record, the nurse can ensure that the right medication is given to the right patient.
Explanation:
a) The client's room number is not a reliable method to confirm the client's identity because multiple clients may be assigned to the same room, and there is a possibility of room changes or transfers.
b) The client's admitting diagnosis is not a suitable method to confirm identity as it does not provide specific information about the individual patient.
c) The name of the client's next of kin is not a reliable method to confirm the client's identity as it refers to a family member or emergency contact, not the client themselves. Additionally, next of kin information may not always be up to date or readily available.
Correct Answer is C
Explanation
The Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each element has a range of one to four points, with a total possible score of 23 points. The lower the score, the higher the risk for pressure injury.
Option a is incorrect because each element has a range from one to four points.
Option b is incorrect because the lower the score, the higher the pressure injury risk.
Option d is incorrect because the client's age is not part of the measurement.
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