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 A
Explanation
Choice A Reason:
A client who has a spinal cord injury is correct. An interprofessional conference is often recommended for clients with complex and multifaceted health issues that require collaboration among various healthcare disciplines. A client with a spinal cord injury typically has complex care needs that involve multiple healthcare professionals, such as physical therapists, occupational therapists, social workers, nurses, and possibly surgeons or neurologists. The coordination of care for a client with a spinal cord injury often requires input and collaboration from various healthcare team members, making an interprofessional conference valuable.
Choice B Reason:
A torn rotator cuff may require physical therapy and orthopedic consultation but may not require the same level of multidisciplinary collaboration as a spinal cord injury.
Choice C Reason:
Acute appendicitis typically involves surgical intervention but may not require the same degree of ongoing interprofessional collaboration as other complex conditions.
Choice D Reason:
A urinary tract infection is a common and relatively straightforward condition that is usually managed by nurses and primary care providers without extensive interprofessional conferences.
Correct Answer is B
Explanation
Choice A Reason:
"I might have occasional seizures for several days after the procedure." This statement is not accurate. ECT does induce a controlled seizure during the procedure, but clients typically do not experience seizures after the treatment. This statement does not indicate an understanding of the procedure.
Choice B Reason:
"I might have short-term memory loss after the procedure. “This statement is accurate. Memory loss is a common side effect of ECT, particularly short-term memory loss. It's important for the client to be aware of this potential side effect.
Choice C Reason:
"I will have a urinary catheter in place during the procedure." This statement is not accurate. A urinary catheter is not typically used during ECT. It's important for the client to have accurate information about the procedure.
Choice D Reason:
"I will need to follow a full-liquid diet for 24 hours after the procedure." This statement is not accurate. Clients undergoing ECT do not usually require a full-liquid diet afterward. The dietary restrictions may vary depending on the facility's policies, but it is not typically a full-liquid diet.
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