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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Support the client's decision to stop the treatment.
As a nurse, it is important to respect the client's autonomy and right to make decisions about their own care. The decision to stop dialysis treatment is a personal one and should be respected by the healthcare team. The nurse should support the client's decision and provide information and resources to help the client manage symptoms and maintain comfort during the end-of-life process.
It is not appropriate for the nurse to suggest that the client discuss the decision with her family or to discuss alternative treatment methods, as these decisions should be made by the client in conjunction with their healthcare provider.
It may be appropriate to offer spiritual or emotional support to the client, but this should be based on the client's preferences and not imposed upon them by the healthcare team.
Correct Answer is A
Explanation
During a mass casualty event, it is crucial for the nurse to assess and determine the acuity level (severity) and number of casualties who will be arriving at the healthcare facility. This information helps in planning and organizing resources, triaging patients based on their needs, and ensuring that appropriate care is provided to those who require immediate attention.
Delegating tasks to emergency health care specialists is a role that may be performed by a nurse in a leadership or supervisory position. However, the immediate priority for the nurse is to assess and triage incoming casualties.
Providing informational updates to members of the media is usually handled by designated spokespersons or communication specialists within the healthcare facility or incident command system. Nurses are primarily focused on patient care and should not be responsible for media communication during a mass casualty event.
Assisting in discharging stable clients to home is not directly related to the immediate response and care of casualties from a mass casualty event. The nurse's focus in such situations is primarily on the management of the incoming casualties and ensuring the availability of resources and care for those who require immediate attention.
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