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 B
Explanation
Choice A reason: Type 2 diabetes mellitus, while a serious chronic condition, does not directly predispose patients to delirium. Diabetes primarily impacts the body's ability to regulate blood glucose levels, leading to complications such as cardiovascular disease, neuropathy, and nephropathy. However, it is not directly linked to the acute cognitive disturbances seen in delirium unless it leads to severe metabolic derangements, which is less common.
Choice B reason: Alcohol abuse is a significant risk factor for the development of delirium, especially in ICU patients. Chronic alcohol use can lead to a condition known as delirium tremens (DTs) during withdrawal, characterized by severe agitation, confusion, hallucinations, and autonomic hyperactivity. Patients with a history of alcohol abuse may have altered brain chemistry and neurotransmitter imbalances that predispose them to delirium when stressed by illness or surgery. Moreover, alcohol abuse can lead to liver dysfunction, nutritional deficiencies (particularly thiamine), and other systemic issues that further exacerbate the risk.
Choice C reason: Anxiety can exacerbate stress and discomfort in a patient but is not a primary causative factor for delirium. Anxiety may contribute to an increased sense of fear or confusion, especially in an ICU setting. However, it does not cause the profound disruption in cognitive function, attention, and awareness that characterizes delirium.
Choice D reason: Impaired communication might be a consequence or symptom seen in patients with delirium, but it is not a root cause. Patients with pre-existing communication difficulties might struggle more to express symptoms or needs, which could complicate care, but it does not inherently lead to the onset of delirium. Effective communication strategies and aids can help manage these challenges but do not address the underlying neurological changes seen in delirium.
Correct Answer is ["A","B"]
Explanation
Choice A reason: Keeping the radiation area clean with mild soap and water helps maintain hygiene and prevent infection. It is important to use gentle, non-irritating cleansers to avoid aggravating the skin that is already sensitive due to radiation.
Choice B reason: Avoiding exposure of the radiation site to extreme temperatures is crucial. Heat can increase irritation, and cold can cause additional discomfort. Protecting the area from extreme temperatures helps in reducing skin reactions and promoting healing.
Choice C reason: Wearing tight clothing is not recommended for patients undergoing radiation therapy. Tight clothing can cause friction and irritation on the already sensitive radiation site, potentially worsening skin reactions.
Choice D reason: Applying fragrant lotions to the radiation area is not advised. Fragrances and certain chemicals in lotions can irritate the skin and lead to adverse reactions. It is better to use unscented, gentle moisturizers if needed.
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