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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.While increasing dietary fiber can help with constipation, a common side effect of iron supplements, it does not directly improve the absorption of the medication
B.Berries and citrus fruits, on the other hand, are good sources of vitamin C, which can actually enhance iron absorption. Therefore, eliminating them from the diet would not be beneficial for improving iron absorption.
C.The recommendation the nurse should make to improve the absorption of the iron supplement (ferrous sulfate) is to avoid drinking milk with the medication. Calcium in milk can interfere with the absorption of iron, so it is best to separate the consumption of these two substances.
D.Green tea contains compounds called tannins, which can interfere with iron absorption. Therefore, it is not recommended to take iron supplements with green tea.
Correct Answer is B
Explanation
An incident report is formal documentation used to report any unexpected or adverse events that occur during the course of patient care. It provides a record of the incident and helps identify areas for improvement in patient safety and quality of care. The incident report should include details about the error, the potential impact on the client, actions taken to address the error, and any necessary follow-up.
A nursing care plan is a document that outlines the client's nursing diagnoses, goals, interventions, and evaluations. It is not the appropriate place to document a medication error or incident.
The provider's progress notes are documentation made by the healthcare provider, typically documenting their assessments, diagnoses, treatment plans, and progress of the client. A medication error made by the nurse should not be documented in the provider's progress notes.
The controlled substance inventory record is a record used to track the dispensing and administration of controlled substances. While it is important to maintain accurate records of controlled substances, documenting a medication error in this record is not the appropriate place as it is primarily used for inventory management purposes
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