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 providing tracheostomy care, the nurse should clean the stoma using an inward to outward circular motion to remove any secretions or debris. It is important to avoid using excessive force or pressure, which can cause trauma to the stoma. Cleansing the inner cannula with isopropyl alcohol may be appropriate for some clients, but it is important to follow the healthcare provider's orders regarding inner cannula care.
When securing the tracheostomy ties, the nurse should ensure that there is enough space for two fingers, not three. Finally, the nurse should prepare sterile supplies before removing the inner cannula to ensure that they are readily available and reduce the risk of infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Correct answer: A
a.This step is crucial because it helps maintain the sterility of the kit by ensuring that the nurse does not accidentally contaminate the sterile field with their body or clothing.This step ensures that the nurse's hands and arms do not cross over the sterile field, reducing the risk of contamination.
b.Opening the flap nearest to the nurse first can lead to contamination because the nurse's hands and arms might cross over the sterile field while opening the remaining flaps. This increases the risk of introducing pathogens into the sterile area, compromising the sterility required for the procedure.
c.Opening a side flap first can also compromise the sterility of the field. Similar to option (b), this action might result in the nurse's hands or arms moving over the sterile area, risking contamination.
d.Applying sterile gloves is an essential step in maintaining sterility, but it is not the first step. The nurse needs to prepare the sterile field before donning sterile gloves to ensure that the gloves themselves remain uncontaminated. If the nurse were to put on sterile gloves first, there is a risk of contaminating the gloves while opening the sterile kit, thereby defeating the purpose of using sterile gloves.
Correct Answer is B
Explanation
b. This must be very frightening for you. Let's talk more about it.
It is important for the nurse to acknowledge the client's fears and show empathy towards them. By saying "This must be very frightening for you," the nurse validates the client's feelings and shows that they are being heard.
Additionally, by suggesting that they talk more about it, the nurse can work towards building a therapeutic relationship with the client and gain more insight into their thought processes.
The other options are not appropriate because:
a. The nurse should not deny the client's beliefs or try to convince them that they are wrong. This can cause
the client to feel invalidated and may make them less likely to trust the nurse.
c. While it is important to understand the client's perspective, this question may come off as confrontational and accusatory.
d. Similarly, this question may be perceived as confrontational and may make the client defensive. It is important to approach the client with empathy and understanding rather than skepticism.
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