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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hepatitis A is primarily transmitted through the fecal-oral route, often due to contaminated food or water. However, it can also spread through close personal contact, including sharing towels, utensils, or other personal items. By using different hand towels than others in the home, the client demonstrates an understanding of the importance of preventing the transmission of the virus.
While hand hygiene is essential in preventing the spread of infectious diseases, including hepatitis A, alcohol-based cleansers are not effective against the hepatitis A virus. Washing hands with soap and water for at least 20 seconds is the recommended method to remove the virus from the hands.
Hepatitis A can be spread through contaminated food, so it is important for the client to avoid preparing food for others during the acute phase of the illness and until cleared by a healthcare professional.
Hepatitis A is not typically transmitted through contact with blood. It is primarily transmitted through the fecal-oral route or close personal contact with an infected individual.
Correct Answer is C
Explanation
Instruct the client to close their mouth tightly around the mouthpiece of the inhaler. This ensures that the medication is delivered directly into the lungs and minimizes the amount of medication escaping into the surrounding environment.
The correct technique for using a metered-dose inhaler does not involve tilting the head forward.
Instead, the client should keep their head in a neutral position while using the inhaler. After inhaling the medication from the inhaler, it is recommended to hold the breath for about 10 seconds before exhaling. This allows the medication to be fully deposited in the lungs and absorbed effectively.
The proper technique for using an albuterol metered-dose inhaler involves taking a slow and deep breath. The client should depress the canister once at the beginning of inhalation and continue to inhale slowly and deeply to ensure adequate medication delivery.
It is important for the nurse to demonstrate and observe the client's technique while using the inhaler to ensure proper administration.
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