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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Cantaloupe and cottage cheese are not particularly high in iron. While cantaloupe provides vitamin C, which can enhance iron absorption, the overall iron content of this meal is low, making it less effective for treating iron-deficiency anemia.
Choice B reason: Cornmeal muffin and orange juice offer some nutrients, including vitamin C from orange juice, which helps with iron absorption. However, cornmeal muffins do not provide significant iron content, making this choice suboptimal for iron-deficiency anemia.
Choice C reason: Strawberry and banana fruit plate provides vitamins and minerals, including vitamin C from strawberries, but it lacks substantial iron content. This choice is not adequate for addressing iron-deficiency anemia.
Choice D reason: Omelet and whole wheat toast are excellent choices for increasing dietary iron intake. Eggs in the omelet provide heme iron, which is easily absorbed by the body, and whole wheat toast contains non-heme iron. Combined, they offer a balanced and effective meal for managing iron-deficiency anemia.
Correct Answer is C
Explanation
Choice A reason: Amber fluid is typically a sign of serous exudate, which is a normal part of the inflammatory process and wound healing. It indicates the body's immune response to the injury and is generally not a cause for concern unless the volume significantly increases or changes in appearance.
Choice B reason: Clear drainage, or serous fluid, is also a normal finding in wound healing. It indicates that the wound is exuding plasma, which helps to keep the wound moist and supports the healing process. This type of drainage is typically not worrisome unless there are other signs of infection or complications.
Choice C reason: Purulent, draining wound is a major concern as it indicates the presence of pus, which is often a sign of infection. Purulent drainage can be yellow, green, or brown and is usually thick and malodorous. The presence of pus suggests that there are bacteria or other pathogens in the wound, and immediate medical intervention is necessary to prevent further complications and promote healing.
Choice D reason: Blood-tinged fluid, or serosanguinous drainage, is common in fresh wounds or after debridement. It indicates a mixture of plasma and red blood cells and can be seen in the early stages of wound healing. While it is generally not alarming, the nurse should monitor the volume and changes in the drainage to ensure there are no signs of excessive bleeding or infection.
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