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
Candidiasis, also known as a yeast infection, commonly presents with symptoms such as a thick, white vaginal discharge. It may also be accompanied by itching, redness, and irritation in the vaginal area. This type of discharge is typically described as resembling cottage cheese in texture. Other symptoms that may occur with candidiasis include burning during urination and discomfort during sexual intercourse.
A hard, painless chancre is a characteristic finding of syphilis, not candidiasis. Frothy, malodorous discharge is commonly associated with bacterial vaginosis, not candidiasis.
Feeling of pelvic heaviness is more commonly associated with conditions like pelvic organ prolapse or uterine fibroids, and is not specific to candidiasis.
Correct Answer is C
Explanation
c. New onset of hearing loss.
When collecting data from a client who is receiving gentamicin via IV infusion, the nurse should identify new onset of hearing loss as an adverse effect of the treatment¹. Gentamicin can cause vestibulocochlear nerve damage, which can affect hearing and balance¹.
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