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 D

Explanation

The cervical cap should be left in place for a minimum of 6 hours after intercourse but should not exceed a total of 48 hours of continuous use. Leaving it in place for longer periods may increase the risk of toxic shock syndrome (TSS) and other potential complications. Using a cervical cap in combination with a spermicide is the recommended practice for maximizing its effectiveness. Spermicide helps immobilize or kill sperm, providing an additional barrier against pregnancy when used with the cervical cap.

Using the cervical cap during the menstrual cycle is not a recommended practice for contraception. The cervical cap is primarily used during sexual activity as a barrier method of contraception and is not specifically designed for use during menstruation.

While it is important for the provider to initially fit and size the cervical cap for the client, routine checks every 6 months are not necessary. However, it is still important for the client to regularly inspect the cap for any signs of damage or deterioration and replace it as needed.

A. Memory loss that disrupts ADLs B. Catatonia C. Illusions D. Pressured speech

Correct Answer is A

Explanation

a. Memory loss that disrupts ADLs

Explanation: Dementia is a condition characterized by a decline in cognitive function that aﬀects a person's ability to perform activities of daily living (ADLs). Memory loss is a common symptom of dementia, particularly in the early stages. The memory loss can disrupt a person's ability to carry out tasks they were previously able to do independently, such as dressing, bathing, and eating. Therefore, option a is the correct answer.

Option b, catatonia, is a condition characterized by a lack of movement or activity, which is not typically associated with dementia.

Option c, illusions, involve a misinterpretation of sensory information and may occur in some forms of dementia but are not a defining feature.

Option d, pressured speech, is a symptom commonly associated with mania or bipolar disorder, but is not typically seen in dementia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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