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

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.

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Correct Answer is C

Explanation

The rotavirus vaccine is administered orally, usually in the form of drops. It is given to infants to protect against rotavirus, which is a common cause of severe diarrhea and dehydration in young children. By stating that the baby will receive the rotavirus immunization orally, the guardian demonstrates an understanding of this specific vaccination.

There is no need to restrict feeding for a specific duration before immunization unless otherwise specified by the healthcare provider. In general, it is important to ensure that the infant is well-fed and hydrated.

While mild side effects such as low-grade fever, fussiness, or local soreness at the injection site may occur after immunizations, having a high fever for 24 hours is not a typical or expected reaction. If a high fever or any concerning symptoms develop after immunization, it is important to contact the healthcare provider.

The number of doses and the schedule for meningococcal immunization can vary depending on the specific vaccine used and the recommendations of the healthcare provider or local guidelines.

A. Prealbumin 13 mg/dL B. Potassium 3.5 mEq/L C. Sodium 138 mEq/L D. Total calcium 10 mg/dL

Correct Answer is A

Explanation

Prealbumin is a protein that is produced by the liver and is an indicator of the body's nutritional status. A low prealbumin level can indicate malnutrition, which is common in clients with COPD. Therefore, a dietary referral can help the client meet their nutritional needs and prevent further complications.

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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?

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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?