A nurse is performing tracheostomy care for a client who has a chronic tracheostomy. Which of the following actions should the nurse take?
Allow space for one finger to be placed under the tube ties.
Apply suction pressure while inserting the catheter into the trachea.
Suction the client for 20 seconds with each pass.
Cleanse around the stoma with povidone-iodine.
The Correct Answer is A
Choice A reason: Allowing space for one finger to be placed under the tube ties is a correct action for tracheostomy care. This ensures that the tube ties are not too tight, which can cause skin breakdown, pressure necrosis, or impaired circulation. The tube ties should also not be too loose, which can cause accidental dislodgement of the tube.
Choice B reason: Applying suction pressure while inserting the catheter into the trachea is an incorrect action for tracheostomy care. This can cause trauma to the tracheal mucosa and increase the risk of infection and bleeding. The nurse should apply suction pressure only while withdrawing the catheter and rotate it gently to remove secretions.
Choice C reason: Suctioning the client for 20 seconds with each pass is an incorrect action for tracheostomy care. This can cause hypoxia, bradycardia, or cardiac arrest due to vagal stimulation. The nurse should suction the client for no more than 10 to 15 seconds with each pass and allow at least 30 seconds between passes for oxygenation.
Choice D reason: Cleansing around the stoma with povidone-iodine is an incorrect action for tracheostomy care. Povidone-iodine is a strong antiseptic that can irritate the skin and cause allergic reactions. The nurse should cleanse around the stoma with normal saline or sterile water and apply a thin layer of water-soluble lubricant to protect the skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1000"]
Explanation
To lose 0.9 kg (2 lb) of body fat per week, the client needs to create a weekly caloric deficit of 7,000 calories (3,500 x 2).
This means that the client needs to consume 7,000 calories less than he burns in a week.
To achieve this, the client needs to reduce his daily caloric intake by 1,000 calories (7,000 / 7).
For example, if the client normally consumes 2,500 calories per day, he should reduce it to 1,500 calories per day.
Correct Answer is D
Explanation
Choice A reason: This medication does not need to be avoided within 24 hours of using nitroglycerin because it does not interact with nitroglycerin. Metformin is an oral antidiabetic drug that lowers blood glucose levels by decreasing hepatic glucose production and increasing insulin sensitivity.
Choice B reason: This medication does not need to be avoided within 24 hours of using nitroglycerin because it does not interact with nitroglycerin. Atorvastatin is a statin drug that lowers blood cholesterol levels by inhibiting an enzyme involved in cholesterol synthesis.
Choice C reason: This medication does not need to be avoided within 24 hours of using nitroglycerin because it does not interact with nitroglycerin. Omeprazole is a proton pump inhibitor drug that lowers stomach acid levels by blocking an enzyme involved in acid secretion.
Choice D reason: This medication needs to be avoided within 24 hours of using nitroglycerin because it can interact with nitroglycerin and cause severe hypotension and syncope. Sildenafil is a phosphodiesterase inhibitor drug that treats erectile dysfunction by increasing blood flow to the penis by relaxing smooth muscle cells.
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