A nurse is contributing to the plan of care for a client who had a tracheostomy placed 2 hr ago. Which of the following interventions should the nurse recommend for the plan of care?

Wear clean gloves when cleansing the tracheostomy site.

Cleanse the tracheostomy site with 0.9% sodium chloride.

Change the client's tracheostomy ties every 72 hr.

Suction the client's tracheostomy every 6 hr.

Answer and Explanation

The Correct Answer is B

A. Wear clean gloves when cleansing the tracheostomy site.
Sterile gloves are required in the immediate post-op period to prevent infection.

B. Cleanse the tracheostomy site with 0.9% sodium chloride.
Isotonic saline is used for routine tracheostomy site cleansing to reduce infection risk.

C. Change the client's tracheostomy ties every 72 hr.
Ties should be changed as needed or per protocol, often more frequently in early post-op period.

D. Suction the client's tracheostomy every 6 hr.
Suction as needed, not on a fixed schedule, to avoid mucosal trauma.

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Correct Answer is []

Explanation

Potential Condition:
Uterine atony
Boggy uterus, heavy bleeding, fundus responds to massage but returns to boggy state.

Actions to Take:
Massage fundus.
First-line measure to stimulate contraction and reduce bleeding.
Administer IV oxytocin.
Oxytocin promotes uterine contractions to reduce bleeding.

Parameters to Monitor:
Amount of lochia.
Helps assess ongoing blood loss.
Urine output.
Indicates perfusion status and potential hypovolemia.

A. A client who is 4 days postpartum and has lochia serosa B. A client who is 3 days postpartum and has not had a bowel movement since prior to admission C. A client who is 1 day postpartum and has not voided in 8 hr D. A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus

Correct Answer is C

Explanation

A. A client who is 4 days postpartum and has lochia serosa
This is an expected finding in the healing process.

B. A client who is 3 days postpartum and has not had a bowel movement
Common postpartum; not urgent unless severe discomfort or obstruction is present.

C. A client who is 1 day postpartum and has not voided in 8 hr
Urinary retention increases the risk of uterine atony and postpartum hemorrhage-must be addressed urgently.

D. A client whose fundus is 2–4 cm below the umbilicus on day 2
Normal involution of the uterus; not concerning.

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A nurse is contributing to the plan of care for a client who had a tracheostomy placed 2 hr ago. Which of the following interventions should the nurse recommend for the plan of care?

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Correct Answer is []

Explanation

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Correct Answer is C

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