A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

Explanation

C. The client has developed difficulty ambulating

The information about the client's difficulty ambulating is relevant to the interprofessional team because it may require input and collaboration from various healthcare professionals to address and manage the client's mobility issues. This information helps the team understand the client's current condition and plan appropriate interventions.

The client having state-sponsored health insurance in (option A) is incorrect because it is not directly relevant to the interprofessional team meeting unless it specifically impacts the client's healthcare options, resources, or access to care. However, it may be important to know for insurance-related discussions or considerations, depending on the purpose of the team meeting.

The client's next dressing change being scheduled in 4 hours in (option B) is incorrect because it is important information for the nurse's own clinical responsibilities, but it may not be directly relevant to the broader interprofessional team meeting unless it has implications for the client's overall care plan or requires input from other team members.

The frequency of the client's vital sign checks being every 8 hours in (option D) is incorrect because it is important for the nurse's routine monitoring and care, but it may not be the primary focus of the interprofessional team meeting unless there are specific concerns or changes in the client's vital signs that need to be addressed collaboratively.

In summary, the nurse should include information about the client's difficulty ambulating during the interprofessional team meeting, as it helps inform the team's discussions, interventions, and plans regarding the client's mobility and potential impact on their overall care.

a.This is not recommended. The central tip of the finger is more sensitive and has more nerve endings, which can cause more pain. The recommended site for blood glucose testing is the side of the fingertip, as it is less sensitive and provides an adequate blood sample.

b. While it is not necessary to wear sterile gloves for routine capillary blood glucose monitoring, it is important to ensure that the nurse's hands are clean. Wearing clean gloves helps maintain infection control practices.

c. After puncturing the selected site, the nurse should gently squeeze the finger to create a small drop of blood. The first drop of blood should be wiped away, and subsequent drops should be used for the glucose test. This ensures that the sample is fresh and not contaminated with tissue fluid.

d.Keeping the finger in a dependent position (hanging down) helps improve blood flow to the fingertip, making it easier to obtain a sufficient blood sample. This can help ensure an accurate glucose reading.