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 B
Explanation
Choice A Reason:
"I should do aerobic exercises once per day." While exercise is important for individuals with COPD, the frequency and intensity of exercise should be determined based on the individual's condition and healthcare provider's recommendations. One-size-fits-all recommendations may not apply to all clients.
Choice B Reason:
"I should practice pursed-lip breathing exercises." Pursed-lip breathing exercises are a beneficial technique for individuals with COPD. This technique can help improve breathing efficiency and decrease shortness of breath. Clients with COPD are often taught to use pursed-lip breathing during activities that require increased effort or when experiencing shortness of breath.
Choice C Reason:
"I will increase my fluid intake to 1,700 milliliters per day." While staying adequately hydrated is essential, the specific fluid intake should be determined based on the client's needs, medical condition, and healthcare provider's advice. The recommended daily fluid intake can vary among individuals.
Choice D Reason:
"I will consume low-protein, low-calorie foods." Nutrition is an important aspect of COPD management, but the dietary recommendations should be tailored to the client's specific needs, including their nutritional status, energy expenditure, and other factors. A generalized statement about low-protein, low-calorie foods may not be appropriate for all individuals with COPD.
Correct Answer is A
Explanation
a. Apply pressure to the lacrimal punctum after administering the drops.
When administering eye drops to a child, the nurse should apply gentle pressure to the lacrimal punctum (the small opening in the inner corner of the eye) after administering the drops. This can help prevent the medication from draining into the tear duct and being absorbed into the bloodstream, which can reduce systemic side effects.
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