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

The correct answer is: a. Clean the stoma using an inward to outward circular motion.

Title: Choice A reason: Cleaning the stoma with an inward to outward circular motion is a recommended practice to prevent infection and ensure that any debris or secretions are cleared away from the tracheostomy site. This method helps to minimize the risk of introducing pathogens directly into the stoma and is considered a best practice in tracheostomy care.

Title: Choice B reason: Cleansing the inner cannula with isopropyl alcohol is not recommended because it can cause irritation to the tracheal mucosa. Instead, sterile saline is typically used for cleaning the inner cannula to avoid any potential damage to the tracheal tissues and to maintain a safe and comfortable environment for the patient.

Title: Choice C reason: Ensuring at least three finger widths of space under tracheostomy ties is not the standard practice. The recommended space is to allow one to two finger widths under the tracheostomy ties to ensure they are secure but not too tight, which could lead to skin breakdown or discomfort for the patient.

Title: Choice D reason: Preparing sterile supplies should be done before removing the inner cannula, not after. This is to ensure that all necessary supplies are ready to use immediately after the inner cannula is removed, minimizing the time the stoma is open and reducing the risk of infection.

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Correct Answer is C

Explanation

Assessing the client's ability to use the call light is crucial for their safety and well-being. If the client is unable to use the call light to request assistance, it increases the risk of falls or accidents when they attempt to move or perform tasks without assistance. By determining the client's ability to use the call light, the nurse can ensure that appropriate measures are in place to enable the client to call for help whenever needed.

Applying rubber-soled slippers before ambulation helps to provide better traction and reduce the risk of slips and falls, but it can be implemented after assessing the client's ability to use the call light.

Moving the bedside table closer to the bed is helpful for the client to access personal items without the need to reach or stretch, but it is not the highest priority among the given options.

Creating a schedule with assistive personnel for hourly rounding is important for regular checks on the client's safety and well-being, but it can be arranged after assessing the client's ability to use the call light.

A. Apply intermittent suction for 30 seconds. B. Insert the catheter 10 cm (4 in). C. Apply suction while inserting the catheter. D. Wait 1 min between suctioning attempts.

Correct Answer is D

Explanation

Waiting 1 minute between suctioning attempts allows the client to recover and ensures that the procedure is not overly invasive. It also helps to prevent the client from becoming hypoxic.

The distance that the nasopharyngeal catheter should be inserted varies from person to person and therefore 10 cm is not standard.

During nasopharyngeal suctioning, the nurse should apply suction intermittently while withdrawing the catheter, not during insertion. Applying suction during insertion can cause tissue damage and increase the risk of trauma.

The nurse should also apply intermittent suction for no longer than 15 seconds to prevent hypoxia and damage to the mucosal lining. Suctioning for an extended period can cause discomfort and harm to the client.

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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?

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