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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This is an indication that the medication has been effective because hemoglobin is a protein in red blood cells that carries oxygen throughout the body and epoetin alfa is a medication that stimulates red blood cell production in clients who have anemia or low hemoglobin levels due to chronic kidney disease, chemotherapy, or surgery. The normal range of hemoglobin for adults is 12 to 18 g/dL.

Choice B reason: This is not an indication that the medication has been effective because WBC count is a measure of white blood cells that fight infection and epoetin alfa does not affect white blood cell production or function in clients who have anemia or low hemoglobin levels due to chronic kidney disease, chemotherapy, or surgery. The normal range of WBC count for adults is 4,500 to 11,000/mm³.

Choice C reason: This is not an indication that the medication has been effective because PT or prothrombin time is a test that measures how long it takes blood to clot and epoetin alfa does not affect blood clotting or coagulation in clients who have anemia or low hemoglobin levels due to chronic kidney disease, chemotherapy, or surgery. The normal range of PT for adults is 11 to 13.5 seconds.

Choice D reason: This is not an indication that the medication has been effective because total calcium is a measure of calcium in the blood that is important for bone and muscle health and epoetin alfa does not affect calcium levels or metabolism in clients who have anemia or low hemoglobin levels due to chronic kidney disease, chemotherapy, or surgery. The normal range of total calcium for adults is 8.5 to 10.2 mg/dL.

A. Describe the food placement as though the plate were a clock. B. Provide the client with small-handled adaptive utensils. C. Discourage conversations during the client's mealtime. D. Arrange for an assistive personnel to feed the client.

Correct Answer is A

Explanation

Choice A reason: This is the correct answer because describing the food placement as though the plate were a clock can help the client locate and identify the food items on their tray. For example, the nurse can say, "Your chicken is at 12 o'clock, your mashed potatoes are at 3 o'clock, and your green beans are at 9 o'clock."

Choice B reason: This is not an appropriate action because providing the client with small-handled adaptive utensils can make it harder for them to grip and manipulate the utensils and increase their frustration and dependence. The nurse should provide the client with large-handled or weighted adaptive utensils that can improve their dexterity and control.

Choice C reason: This is not an appropriate action because discouraging conversations during the client's mealtime can make them feel isolated and depressed and reduce their appetite and enjoyment of food. The nurse should encourage conversations during the client's mealtime and provide social support and stimulation.

Choice D reason: This is not an appropriate action because arranging for an assistive personnel to feed the client can compromise their dignity and autonomy and increase their dependence and helplessness. The nurse should respect the client's preferences and abilities and provide assistance only when necessary.

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