A nurse is caring for a client who has a tracheostomy.
Which of the following actions should the nurse take?
Secure the tracheostomy ties to allow one finger to fit snugly underneath.
Cleanse the skin around the stoma with normal saline.
Soak the outer cannula in warm, soapy tap water.
Use a cotton tip applicator to clean inside the inner cannula.
The Correct Answer is A
Secure the tracheostomy ties to allow one finger to fit snugly underneath. This is important to ensure that the tracheostomy tube is secure and in place.
Choice B is wrong because normal saline is not typically used to cleanse the skin around the stoma.
Choice C is wrong because soaking the outer cannula in warm, soapy tap water is not a recommended method of cleaning.
Choice D is wrong because a cotton tip applicator should not be used to clean inside the inner cannula.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
“Delirium has an abrupt onset.” Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of someone’s surroundings.
The disorder usually comes on fast — within hours or a few days.
Choice A is wrong because delirium does affect a client’s perception of her environment.
Choice B is wrong because delirium does not have a slow progression, but rather an abrupt onset.
Choice C is wrong because delirium can affect a client’s sleep cycle.
Correct Answer is D
Explanation
In general, parental (or legal guardian) consent is required for any diagnostic or surgical procedure performed on a child under the age of 181.
Choice A is wrong because the mother’s 21-year-old sibling is not a parent or legal guardian of the infant.
Choice B is wrong because the infant’s provider cannot sign the consent form on behalf of the infant.
Choice C is wrong because the infant’s grandparent cannot sign the consent form unless they are a legal guardian of the infant.
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