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
The correct answer is b. Respiratory depression.
Choice A: Pupillary dilation This is incorrect. Opioid toxicity typically causes pupillary constriction, often referred to as pinpoint pupils. This is the opposite of pupillary dilation.
Choice B: Respiratory depression This is correct. Opioids can excessively stimulate the part of your brain that regulates breathing, leading to respiratory depression. This is a common and significant symptom of opioid toxicity.
Choice C: Chest pain This is not a typical symptom of opioid toxicity. While chest pain can occur in various conditions, it is not specifically associated with opioid toxicity. Therefore, this choice is incorrect.
Choice D: Diaphoresis This is not a typical symptom of opioid toxicity. While diaphoresis (excessive sweating) can occur in various conditions, it is not specifically associated with opioid toxicity. Therefore, this choice is incorrect.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because pneumococcal vaccine can prevent pneumococcal disease, which is caused by bacteria that can infect the lungs, blood, or brain and cause serious complications, especially in older adults. The nurse should recommend that adults aged 65 years or older receive one dose of pneumococcal conjugate vaccine (PCV13) followed by one dose of pneumococcal polysaccharide vaccine (PPSV23) at least one year later.
Choice B reason: This is not an appropriate immunization for this client because HPV vaccine can prevent HPV infection, which can cause genital warts and cervical cancer in women and other cancers in men and women. The nurse should recommend that adolescents aged 11 to 12 years receive two doses of HPV vaccine six to twelve months apart.
Choice C reason: This is not an appropriate immunization for this client because MMR vaccine can prevent measles, mumps, and rubella infections, which are highly contagious viral diseases that can cause serious complications, especially in pregnant women and infants. The nurse should recommend that children receive two doses of MMR vaccine at 12 to 15 months and 4 to 6 years of age.
Choice D reason: This is not an appropriate immunization for this client because tuberculosis vaccine, also known as bacille Calmette-Guérin (BCG) vaccine, can prevent tuberculosis infection, which is caused by bacteria that can affect the lungs and other organs and cause serious complications, especially in people with weakened immune systems. The nurse should recommend that people who live in or travel to countries where tuberculosis is common or who have close contact with someone who has active tuberculosis receive BCG vaccine.
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