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
Cotton underwear is recommended for individuals with UTIs because it allows better air circulation and helps keep the genital area dry. This can prevent the growth of bacteria and reduce the risk of further infection.
Drink orange juice daily for 3 to 4 weeks: While hydration is important for overall health, there is no specific recommendation to drink orange juice or any specific juice for the treatment of a UTI. It is generally recommended to increase fluid intake, particularly water, to help flush out the bacteria from the urinary system.
Take the prescribed antibiotic until manifestations are gone: This instruction is correct. It is important for the client to take the full course of the prescribed antibiotic as directed by their healthcare provider, even if symptoms improve before completing the entire course. This helps ensure complete eradication of the bacteria and reduces the risk of antibiotic resistance.
Restrict fluid intake to 1 L per day: Adequate fluid intake is important for UTI management as it helps flush out bacteria from the urinary system. Restricting fluid intake to 1 liter per day is not recommended and may not provide sufficient hydration. It is generally advised to drink plenty of water and other fluids throughout the day.
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.
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