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 A
Explanation
Choice A reason: This value should be reported to the provider because it indicates an elevated blood urea nitrogen (BUN) level, which can reflect impaired renal function or dehydration. The normal range of BUN is 7 to 20 mg/dL. NSAIDs can cause renal toxicity by reducing blood flow to the kidneys and interfering with their ability to filter waste products.
Choice B reason: This value does not need to be reported to the provider because it indicates a normal hematocrit level, which measures the percentage of red blood cells in the blood volume. The normal range of hematocrit is 38% to 50% for men and 34% to 45% for women.
Choice C reason: This value does not need to be reported to the provider because it indicates a normal total bilirubin level, which measures the amount of bilirubin in the blood that results from the breakdown of red blood cells by the liver. The normal range of total bilirubin is 0.3 to 1.2 mg/dL.
Choice D reason: This value does not need to be reported to the provider because it indicates a normal partial pressure of oxygen (PaO2) level, which measures the amount of oxygen dissolved in the arterial blood. The normal range of PaO2 is 80 to 100 mm Hg.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because an occupational therapist can help the client regain function and mobility in the affected limb, prevent contractures and muscle atrophy, and provide adaptive equipment and strategies to perform daily activities.
Choice B reason: This is not an appropriate referral for this client because a social worker can help with psychosocial issues, financial resources, and community services, but not with physical rehabilitation.
Choice C reason: This is not an appropriate referral for this client because a herbalist can provide alternative or complementary therapies using plants or herbs, but not with evidence-based interventions for disuse syndrome.
Choice D reason: This is not an appropriate referral for this client because a dietitian can help with nutritional counseling and dietary modifications, but not with physical rehabilitation.
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