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
A. Explain the techniques of esophageal speech.Although teaching esophageal speech is important, the use of an artificial larynx may be more immediately relevant and easier for the client to learn and use right after surgery.
B. Schedule a support session for the client.While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.
C. Determine the client's reading ability.This may be relevant for assessing the client's ability to understand written instructions, but it is not as directly related to their immediate post-operative needs for communication.
D. Review the use of an artificial larynx with the client.This intervention is the priority because the client will need to know how to use an artificial larynx to facilitate communication after losing their natural voice. This understanding is critical for the client’s post-operative adjustment and ability to express themselves.
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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