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:
Wipe any excess medication from the inner canthus outward. When administering ophthalmic ointment to a child, it's essential to apply the medication gently and accurately. To prevent the spread of infection and ensure proper absorption, the nurse should instruct the guardian to wipe any excess medication from the inner canthus (the inner corner of the eye) outward. This technique helps to prevent contamination of the medication tube and minimizes the risk of introducing bacteria into the eye.
Choice B Reason:
Placing an occlusive dressing on the affected eye is not necessary for treating acute bacterial conjunctivitis.
Choice C Reason:
Instructing the guardian to apply erythromycin ophthalmic ointment is incorrect because the child has been prescribed bacitracin ophthalmic ointment.
Choice D Reason:
Massaging the eyelid is not necessary and can be uncomfortable for the child. It's important to apply the medication gently and not to massage the eyelid.
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.
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