A nurse is preparing a room for a client who has a tracheostomy tube. Which of following supplies should the nurse place in the room?
Povidone-iodine.
Obturator.
Irrigation set.
Hemostats.
The Correct Answer is B
Obturator.
An obturator is a device that is inserted into the tracheostomy tube to guide it through the stoma and prevent tissue damage. It should be removed after the tube is inserted and kept near the bedside in case of accidental decannulation.
Choice A is wrong because povidone-iodine is an antiseptic solution that is not routinely used for tracheostomy care. It can cause skin irritation and damage to the mucous membranes.
Choice C is wrong because an irrigation set is not needed for a tracheostomy tube.
Irrigation can introduce bacteria and increase the risk of infection. It can also cause coughing and bleeding.
Choice D is wrong because hemostats are not used for a tracheostomy tube.
Hemostats are surgical instruments that are used to clamp blood vessels or tissues. They have no role in tracheostomy care.
Some other supplies that the nurse should place in the room are a trach tube the same size as the current tube and one size smaller, a portable suction machine with battery backup, and tubing that connects to the suction machine. Other supplies may include saline solution, syringes, gauze squares, gloves, a trachea tube brush, a waterproof drape, non-woven sponges, pipe cleaners, cotton tipped applicators, a T-drain sponge, twill tape, a trach holder, a speaking valve, a stoma cover, and a nebulizer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.
Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.
The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.
Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.
Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.
The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.
Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.
Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.
It consists of old blood, serum, leukocytes, and tissue debris.
Correct Answer is C
Explanation
This can be a sign of preeclampsia, a serious complication of pregnancy that causes high blood pressure and proteinuria.
The nurse should report this finding to the provider and monitor the client’s blood pressure, urine protein, and reflexes.
Choice A is wrong because leg cramps are a common discomfort during pregnancy and are not usually a sign of a complication.
Choice B is wrong because ptyalism, or excessive salivation, is a normal physiological change during pregnancy and does not indicate a problem.
Choice D is wrong because melasma, or darkening of the skin on the face, is also a normal physiological change during pregnancy and does not pose a risk to the mother or the fetus.
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