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 ["B","C","D"]
Explanation
Choice A reason: Fluid restrictions are not appropriate for stabilizing a patient with acute anemia. In fact, patients with anemia might require fluid resuscitation to maintain adequate blood volume and pressure. Restricting fluids could potentially worsen the patient's condition.
Choice B reason: Iron supplements are necessary for patients with acute anemia, especially if the anemia is due to iron deficiency. Supplementation helps replenish iron stores in the body, aiding in the production of hemoglobin and red blood cells which are critical for carrying oxygen to tissues.
Choice C reason: PRBC (Packed Red Blood Cells) transfusion is a common and effective intervention for acute anemia. It quickly increases the number of red blood cells in the patient's circulation, thereby improving oxygen delivery to tissues and alleviating symptoms of anemia such as fatigue and weakness.
Choice D reason: O2 therapy, or oxygen therapy, is crucial for stabilizing patients with acute anemia. Anemia results in reduced oxygen-carrying capacity of the blood, and supplemental oxygen helps ensure that tissues receive sufficient oxygen. This intervention can be lifesaving in severe cases of anemia.
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