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 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.
Correct Answer is C
Explanation
Bacterial meningitis is a serious infection of the membranes surrounding the brain and spinal cord that can cause inflammation and damage to the nervous system.
Nuchal rigidity refers to stiffness and pain in the neck that makes it difficult to flex the neck forward. This finding is indicative of inflammation of the meninges and is a classic sign of meningitis.
Pedal edema refers to swelling of the feet and ankles and can be caused by various conditions such as heart, liver, or kidney problems.
Jaundice refers to yellowing of the skin and eyes and can be caused by liver or bile duct disease.
Hematuria refers to the presence of blood in the urine and can be caused by various conditions such as urinary tract infections, kidney stones, or bladder cancer. These findings are not related to bacterial meningitis and may suggest other health concerns that require further evaluation and management.
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