Which action would the nurse take while providing home care to a patient with a stoma after a tracheostomy? Select all that apply. One, some, or all responses may be correct.

Clean the stoma two times a week.

Use a bedside humidifier.

Offer plenty of fluids to the patient.

Keep the stoma uncovered when the patient showers.

Answer and Explanation

Correct Answer : B

Choice A reason: Cleaning the stoma two times a week is not sufficient. Stoma care typically requires daily cleaning to prevent infection and ensure the area remains free from mucus buildup and irritation.

Choice B reason: Using a bedside humidifier is important for patients with a tracheostomy. The humidified air helps to keep the stoma and airway moist, preventing drying and crusting of secretions, which can obstruct the airway.

Choice C reason: Offering plenty of fluids to the patient helps to keep the mucus thin and easier to clear, which is crucial for maintaining a clear airway in patients with a tracheostomy.

Choice D reason: Keeping the stoma uncovered when the patient showers is incorrect. The stoma should be covered with a waterproof shield or dressing to prevent water from entering the airway, which can cause respiratory distress or infection.

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Correct Answer is A

Explanation

Choice A reason: Synthroid (levothyroxine) is the most commonly prescribed medication for hypothyroidism. It is a synthetic form of thyroxine (T4), which replaces the deficient hormone in patients with hypothyroidism and helps normalize their thyroid function.

Choice B reason: PTU (Propylthiouracil) is typically used for the treatment of hyperthyroidism, not hypothyroidism. It works by inhibiting the synthesis of thyroid hormones.

Choice C reason: Tapazole (methimazole) is also used for the treatment of hyperthyroidism, similar to PTU. It is not used to treat hypothyroidism.

Choice D reason: Propranolol is a beta-blocker that is used to manage symptoms of hyperthyroidism, such as tremors and palpitations. It does not treat hypothyroidism.

A. Stage 2 B. Stage 1 C. Stage 3 D. Stage 4

Correct Answer is C

Explanation

Choice A reason: Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Since the wound involves subcutaneous tissue, it exceeds the criteria for Stage 2.

Choice B reason: Stage 1 pressure injuries are characterized by non-blanchable erythema of intact skin. While the skin is still intact, it may appear red and not lighten when pressed. Given the description of a wound involving subcutaneous tissue, Stage 1 is not appropriate.

Choice C reason: Stage 3 pressure injuries involve full-thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible, but the depth of tissue damage varies by anatomical location. This aligns with the wound involving subcutaneous tissue.

Choice D reason: Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. While the wound described involves subcutaneous tissue, there is no mention of deeper tissue involvement, excluding Stage 4 classification.

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Which action would the nurse take while providing home care to a patient with a stoma after a tracheostomy? Select all that apply. One, some, or all responses may be correct.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is being discharged home for treatment of hypothyroidism. Which medication is most commonly prescribed for this condition?

Correct Answer is A

Explanation

A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury?

Correct Answer is C

Explanation

The nurse admits a patient with a low BP who reports severe diarrhea for several days from a Clostridium difficile infection. Which IV fluid would the nurse associate with the need to rapidly replace the patient's fluid volume?

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