A nurse is planning to perform tracheostomy care for a toddler. Which of the following is an appropriate action for the nurse to take?
Place the child in Trendelenburg position when performing care.
Use clean technique to change the tracheostomy tube.
Have the child flex his head when securing the ties.
Clean around the stoma with full-strength hydrogen peroxide.
The Correct Answer is C
A. Placing the child in the Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.
B. Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.
C. This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.
D. Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This statement demonstrates understanding. Elevating the broken arm on pillows can help reduce swelling and promote comfort during the night.
B. Limiting the use of the fingers of the broken arm is important for proper healing.
However, the client should still engage in gentle range-of-motion exercises as instructed by the healthcare provider.
C. Expecting some degree of swelling in the fingers is normal after the application of a cast. This statement shows understanding.
D. Sprinkling baby powder into the cast if the arm itches is not recommended. It can cause irritation and is not an effective way to address itching under the cast. The client should be instructed not to insert anything into the cast.
Correct Answer is C
Explanation
A. Administering an antidepressant is an important intervention for a client with major depressive disorder. However, before initiating any treatment, it is crucial to assess the client's risk for self-harm or suicidal ideation.
B. Assisting the client in completing activities of daily living (ADLs) is important for their overall well-being, but the most immediate concern for a client with major depressive disorder is to assess their safety and risk for self-harm.
C. Correct. Assessing the client's risk for self-harm or suicidal ideation is the first priority.
This information will help determine the level of intervention and support needed.
D. Encouraging the client to attend group therapy is a valuable intervention, but it is not the first priority. Safety concerns must be addressed before implementing other
therapeutic interventions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
