A nurse is preparing to provide tracheostomy care for a client.
Which of the following actions should the nurse plan to take?
Clean the stoma using an inward to outward circular motion.
Cleanse the inner cannula with isopropyl alcohol.
Ensure at least three finger widths of space under tracheostomy ties.
Prepare sterile supplies after removing the inner cannula.
The Correct Answer is A
a. Clean the stoma using an inward to outward circular motion.
When performing tracheostomy care, the nurse should clean the stoma from the inside outward in a circular motion. This technique reduces the risk of introducing pathogens to the stoma site by moving debris away from the incision rather than toward it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
A. Irregular menses is incorrect. Oral contraceptives are often prescribed to regulate menstrual cycles and can be a suitable option for clients with irregular menses.
Choice B Reason:
Vaginal yeast infection is incorrect. Vaginal yeast infections do not generally contraindicate the use of oral contraceptives.
Choice C Reason:
Hypertension (high blood pressure) is a contraindication for the use of oral contraceptives. Women with hypertension are at an increased risk of cardiovascular complications when taking hormonal contraceptives. It is important to assess and manage blood pressure before considering the use of oral contraceptives. If a client has hypertension, alternative methods of contraception should be discussed with the healthcare provider.
Choice D Reason:
History of ectopic pregnancy is incorrect. A history of ectopic pregnancy may not be a contraindication for oral contraceptives, but it is essential for the healthcare provider to assess the client's individual medical history and discuss the risks and benefits.
Correct Answer is D
Explanation
Choice A Reason:
"I moved the television to my bedroom for background noise." Having a television in the bedroom can be disruptive to sleep because it can interfere with relaxation and contribute to increased screen time before bed.
Choice B Reason:
"I go to the 24-hour gym shortly before I go to bed." Exercising shortly before bedtime can stimulate the body and make it more difficult to fall asleep. It's generally recommended to finish exercise at least a few hours before bedtime.
Choice C Reason:
"I am eating dinner later in the evening." Eating a heavy meal or eating too close to bedtime can lead to discomfort and indigestion, making it harder to sleep. It's better to have dinner at least a few hours before bedtime.
Choice D Reason:
"I am going to bed at the same time every night." The statement "I am going to bed at the same time every night" indicates an understanding of sleep promotion because it reflects consistency in the client's sleep schedule. Maintaining a regular sleep schedule helps regulate the body's internal clock and promotes healthy sleep patterns.
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