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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason:

"I will get you information about some head-covering options." This response shows empathy and a willingness to provide practical support to the client. It addresses the client's concerns about hair loss and offers assistance in finding head-covering options, which can be helpful during chemotherapy. It demonstrates a proactive and caring approach to the client's needs.

Choice B Reason:

"I wouldn't worry about this right now. Let's focus on your chemotherapy." This response dismisses the client's concerns and does not provide any support or information.

Choice C Reason:

"Let's discuss this when we have more time. “This response delays addressing the client's concerns and does not offer immediate support or information.

Choice D Reason:

"I can't imagine how difficult it would be to lose my hair." This response expresses personal empathy but does not offer practical assistance or information to the client about managing hair loss.

A. Establish learning outcomes. B. Schedule a time to implement the program. C. Create handouts for participants. D. Determine the literacy level of participants.

Correct Answer is D

Explanation

Understanding the literacy level of the older adults is crucial for developing an effective education program. It helps the nurse tailor the content, language, and teaching methods to ensure that the material is accessible and understandable to the participants. By assessing their literacy level, the nurse can identify any potential barriers to learning and make appropriate adjustments to promote effective communication and comprehension.

Once the literacy level is determined, the nurse can then proceed with the other actions, such as establishing learning outcomes, scheduling a time to implement the program, and creating handouts that are suitable for the participants' literacy level. However, determining the literacy level should be the first step in order to create an inclusive and effective educational experience for the older adults.

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A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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A nurse is preparing to provide tracheostomy care for a client.

Which of the following actions should the nurse plan to take?