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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: A hemoglobin level of 12.0 g/dL is slightly below the normal range for men but is not the most critical concern preoperatively. It indicates mild anemia, which should be monitored but does not present an immediate high risk.

Choice B reason: A serum creatinine level of 1.3 mg/dL is slightly elevated and indicates mild renal impairment. While this should be considered, it is not as immediately concerning as a significantly abnormal coagulation value.

Choice C reason: A Blood Urea Nitrogen (BUN) level of 24 mg/dL is slightly above normal, indicating some renal function impairment or dehydration. However, it does not pose the most significant immediate risk compared to a high INR value.

Choice D reason: An INR of 3.5 is significantly elevated and indicates a high risk of bleeding. For a surgical patient, this is the most concerning pre-op lab value because it suggests that the patient's blood is not clotting properly. This increases the risk of excessive bleeding during and after surgery, making it a priority to address before proceeding with the operation.

A. Inform the patient that the pain medication is contraindicated and offer to dim the room lights. B. Monitor the patient closely after administering the ibuprofen for pain. C. Consult the healthcare provider about ordering a different pain medication. D. Administer the ibuprofen as ordered since ibuprofen is used to treat headaches.

Correct Answer is C

Explanation

Choice A reason: Informing the patient that the pain medication is contraindicated and offering to dim the room lights addresses the immediate concern but does not provide an effective solution for pain management. While it's important to inform the patient, alternative pain relief should be pursued.

Choice B reason: Monitoring the patient closely after administering ibuprofen for pain does not ensure patient safety, especially since ibuprofen can worsen kidney function in patients with acute renal failure. Administering ibuprofen is contraindicated in this case.

Choice C reason: Consulting the healthcare provider about ordering a different pain medication is the safest first step. This ensures that the patient receives an appropriate pain reliever that does not further compromise their renal function. The healthcare provider can prescribe a medication that is safe for patients with acute renal failure.

Choice D reason: Administering ibuprofen as ordered since it is used to treat headaches is not appropriate in this scenario. Ibuprofen is nephrotoxic and can worsen renal function in patients with acute renal failure, making it unsafe to administer.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is D

Explanation

Correct Answer is C

Explanation

When caring for a patient with Alzheimer's disease, the nurse would assess the patient for which two common infection-related complications due to chronic dementia?

Deep vein thrombosis (DVT) and venous thromboembolism (VTE) prevention methods include which of the following? Select all that apply.

Your spinal cord injury (SCI) patient complains of a throbbing headache and nausea. You observe the patient has marked diaphoresis, and you think the patient may have autonomic dysreflexia. Place the following interventions in the order you would complete them.

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?

The nurse identifies which patient condition may be treated with a tissue plasminogen activator?

Which patient statement indicates to the nurse that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH)?