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 B
Explanation
Choice A reason: This is not a food that the nurse should recommend because oatmeal is high in fiber and phytates, which are compounds that can bind to iron and reduce its absorption in the gastrointestinal tract. The nurse should advise the client to avoid consuming foods high in fiber or phytates within 2 hours before or after taking ferrous sulfate.
Choice B reason: This is a food that the nurse should recommend because raw oranges are high in vitamin C, which is an antioxidant that can enhance iron absorption by reducing it to its more soluble form. The nurse should advise the client to consume foods high in vitamin C, such as citrus fruits, tomatoes, or peppers, along with ferrous sulfate.
Choice C reason: This is not a food that the nurse should recommend because cheese is high in calcium and casein, which are substances that can interfere with iron absorption by forming insoluble complexes with it. The nurse should advise the client to avoid consuming foods high in calcium or casein, such as dairy products, eggs, or soybeans, within 2 hours before or after taking ferrous sulfate.
Choice D reason: This is not a food that the nurse should recommend because baked potatoes are high in starch and oxalates, which are compounds that can inhibit iron absorption by forming insoluble salts with it. The nurse should advise the client to avoid consuming foods high in starch or oxalates, such as potatoes, spinach, or rhubarb, within 2 hours before or after taking ferrous sulfate.
Correct Answer is B
Explanation
Choice A reason: This is not an appropriate action because using safety pins to secure the pad in place can puncture or damage the pad and cause leakage or malfunction. The nurse should use Velcro straps or tape to secure the pad in place.
Choice B reason: This is an appropriate action because covering the pad prior to use can prevent direct contact between the pad and the skin and reduce the risk of burns or irritation. The nurse should use a clean towel or sheet to cover the pad.
Choice C reason: This is not an appropriate action because applying the pad for 45 minutes at a time can cause tissue damage or necrosis due to prolonged exposure to heat. The nurse should apply the pad for no more than 20 minutes at a time and check the skin condition frequently.
Choice D reason: This is not an appropriate action because filling the pad with sterile water can increase the cost and waste of resources without any benefit. The nurse should fill the pad with tap water as instructed by the manufacturer.
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