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
a. Clean the stoma using an inward to outward circular motion.
When providing tracheostomy care, the nurse should clean the stoma using an inward to outward circular motion to remove any secretions or debris. It is important to avoid using excessive force or pressure, which can cause trauma to the stoma. Cleansing the inner cannula with isopropyl alcohol may be appropriate for some clients, but it is important to follow the healthcare provider's orders regarding inner cannula care.
When securing the tracheostomy ties, the nurse should ensure that there is enough space for two fingers, not three. Finally, the nurse should prepare sterile supplies before removing the inner cannula to ensure that they are readily available and reduce the risk of infection.
Nursing Test Bank
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 B
Explanation
It is important to provide choices for the client, but limit them to two or three options to prevent confusion and decision-making difficulties.
Use visual cues to assist the client with locating the bathroom, such as pictures or color-coded signs instead of written signs.
Avoid using confrontation to manage the client's behavior, as it can increase agitation and aggression. Instead, use redirection and positive reinforcement.
Provide a calm and non-stimulating environment for the client, as overstimulation can lead to confusion and agitation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.