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","C"]

Explanation

Choice A reason: Performing assisted coughing is crucial for patients with spinal cord injuries who may have weakened respiratory muscles. Assisted coughing helps clear secretions from the airways, thus improving oxygenation and preventing respiratory complications like pneumonia.

Choice B reason: Administering steroids is not a primary intervention for addressing hypoxia in patients with spinal cord injuries. Steroids can be used to reduce inflammation, but they do not directly improve respiratory status or oxygenation.

Choice C reason: Administering oxygen is a direct and effective intervention for managing hypoxia. Supplemental oxygen helps ensure that the patient maintains adequate blood oxygen levels, which is critical for overall tissue perfusion and function.

Choice D reason: Administering antibiotics is not immediately relevant to the treatment of hypoxia unless there is an underlying infection causing or contributing to respiratory distress. Antibiotics are used to treat infections, not directly to improve respiratory status in cases of hypoxia.

A. Health care provider (MD, NP) B. Licensed practical/vocational nurse (LPN/LVN) C. Nursing Supervisor D. Registered nurse (RN)

Correct Answer is D

Explanation

Choice A reason: Health care providers such as medical doctors (MDs) and nurse practitioners (NPs) are responsible for diagnosing and treating medical conditions. While they play a crucial role in patient care, the development of a detailed, individualized nursing plan of care typically falls under the domain of nursing professionals.

Choice B reason: Licensed practical/vocational nurses (LPNs/LVNs) provide basic patient care under the supervision of registered nurses and physicians. They assist with implementing care plans but do not usually develop comprehensive nursing plans of care themselves.

Choice C reason: Nursing supervisors oversee the nursing staff and ensure that nursing care is delivered effectively. They may be involved in developing and overseeing care plans at a higher level but are not typically responsible for creating the individualized care plans for each patient.

Choice D reason: Registered nurses (RNs) are trained and licensed to develop individualized care plans that include nursing diagnoses, interventions, and outcomes. They work closely with patients to create and implement care plans that address specific health needs and promote self-management.

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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

The arterial blood gas (ABG) report of a patient with a spinal cord injury indicates hypoxia. Select two interventions the nurse would perform to improve the patient's respiratory status.

Correct Answer is ["A","C"]

Explanation

In any clinical setting, which health care team member is responsible for developing an individualized plan of care that includes nursing diagnoses, interventions, and outcomes including the patient's self-management care plan?

Correct Answer is D

Explanation

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