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 B
Explanation
This statement shows that the client understands the importance of regularly checking the oxygen equipment for proper functioning and potential issues. Regular equipment checks help ensure the client's safety and effective oxygen therapy.
Adjusting the oxygen flow rate should be done based on the healthcare provider's instructions and not solely based on subjective feelings. The client should follow the prescribed flow rate and consult their healthcare provider if experiencing increased shortness of breath.
Isopropyl alcohol is not recommended for cleaning the nasal cannula as it can cause drying and irritation. The client should use mild soap and water for cleaning the nasal cannula as per the healthcare provider's instructions.
Synthetic blankets can generate static electricity, which could be a fire hazard in the presence of oxygen. The client should be advised to use cotton or wool blankets, which are non-flammable and safer with oxygen therapy.
Correct Answer is B
Explanation
b. Increased urinary output.
Furosemide is a diuretic medication that helps remove excess fluid from the body by increasing urine production and output. In a client with heart failure, one of the indicators that the medication is effective is an increase in urinary output. This can help reduce fluid buildup in the body, which can improve symptoms of heart failure.
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