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 B
Explanation
This response allows the nurse to actively listen to the client, gain a better understanding of their concerns and reasons behind wanting to stop treatment, and open the door for a more in-depth conversation. It demonstrates a non-judgmental approach and creates an opportunity for the client to express their fears, concerns, or any other factors influencing their decision.
"I would feel the same way if I were you." This response reflects the nurse's personal opinion and may not accurately represent the client's thoughts or feelings. It does not encourage the client to explore their own feelings or provide an opportunity for open communication.
"Why do you think that would be a good choice?" This response may come across as confrontational and judgmental, potentially making the client defensive or shutting down communication. It does not facilitate a therapeutic conversation or encourage the client to express their emotions and concerns openly.
"You'll be cancer-free after you complete your treatments." This response may oversimplify the client's situation or offer false reassurance. It is important to acknowledge the client's feelings and concerns while providing accurate information and support, rather than making unrealistic promises about treatment outcomes.
The nurse should approach the client's expression of wanting to stop treatment with empathy, active listening, and an open mind to provide the necessary support, education, and resources to help the client make informed decisions about their healthcare.
Correct Answer is C
Explanation
When collecting a stool specimen to check for occult blood, it is important to avoid certain foods that can affect the test results, such as red meat. Red meat can cause false-positive results due to the presence of heme, which can mimic the appearance of blood in the stool.
By avoiding red meat for at least three days before the test, the client can help ensure more accurate results. pasteurized dairy products do not have a direct impact on stool occult blood test results. However, it is important to note that certain medications, such as bismuth subsalicylate (found in Pepto-Bismol), can affect the test results.
The presence of urine in the stool sample can potentially dilute or mask the presence of blood, leading to false-negative results. It is important
Occult blood testing is typically done as a one-time test unless otherwise specified by a healthcare provider. Collecting a specimen once each week for four weeks is unnecessary unless specifically instructed by the healthcare provider.
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