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.

Answer and Explanation

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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Correct Answer is A, C, B, D

Explanation

First, the nurse should palpate the brachial pulse site to locate the artery. Next, the nurse should inﬂate the blood pressure cuﬀ to 30 mm Hg beyond where the brachial pulse was last felt. The nurse should then discontinue palpation of the brachial pulse and deﬂate the blood pressure cuﬀ slowly until the brachial pulse is detected. This is the point at which the systolic blood pressure can be read.

A. Find an assistive personnel who speaks the client's language. B. Ask a family member of the client to translate for the nurse. C. Arrange for a video conference with an interpreter who speaks the client's language. D. Speak to the client while indicating printed instructions in the client's language.

Correct Answer is C

Explanation

The nurse should arrange for a video conference with an interpreter who speaks the client's language to provide discharge instructions. This ensures that the client receives accurate and complete information in a language they understand. The other

a. Assistive personnel may not be trained or qualified to provide medical interpretation.

b. Family members may not have the necessary medical knowledge to accurately translate medical information.

d. Simply indicating printed instructions in the client's language may not be sufficient to ensure the client understands the information.

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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

A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuﬀ to the client's arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is A, C, B, D

Explanation

A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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