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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.
a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.
c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.
d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.
Correct Answer is B
Explanation
Cellulitis is a contraindication to receiving acupuncture treatment. Acupuncture involves the insertion of needles into the skin, and if the client has an active skin infection such as cellulitis, there is a risk of spreading the infection.
Option a is incorrect because hypertension is not a contraindication to receiving acupuncture.
Option c is incorrect because obesity is not a contraindication to receiving acupuncture.
Option d is incorrect because migraines are not a contraindication to receiving acupuncture; in fact, acupuncture may be used to treat migraines.
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