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.

Use a cotton tip applicator to clean inside the inner cannula.

Cleanse the skin around the stoma with normal saline.

Soak the outer cannula in warm, soapy tap water.

Answer and Explanation

The Correct Answer is A

When caring for a client who has a tracheostomy, the nurse should secure the tracheostomy ties to allow one finger to fit snugly underneath. This helps ensure that the tracheostomy tube is secure and prevents accidental dislodgement.
b)   A cotton tip applicator should not be used to clean inside the inner cannula as it can leave fibers behind
and increase the risk of infection.
c)   The skin around the stoma should be cleansed with sterile saline, not normal saline, to reduce the risk of infection.
d)   The outer cannula should not be soaked in warm, soapy tap water as this can introduce bacteria and increase the risk of infection.

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Correct Answer is A

Explanation

Decreased judgment is a common sign of sleep deprivation. When a person is sleep deprived, their cognitive function can be impaired, leading to difficulty making decisions and exercising good judgment.

Options b, c, and d are not necessarily indicative of sleep deprivation. Decreased activity can be a sign of many diﬀerent conditions, including fatigue or depression. Increased reﬂexes and increased auditory alertness are not commonly associated with sleep deprivation.

A. Encourage the client to make choices regarding hygiene. B. Oﬀer the client sips of a citrus ﬂavored soda. C. Position the client supine in bed. D. Suction the client's airway every hour.

Correct Answer is A

Explanation

When providing end-of-life care for a client, the nurse should encourage the client to make choices regarding their hygiene. This allows the client to have some control over their care and can help them feel more comfortable.

Option b is incorrect because oﬀering the client sips of a citrus ﬂavored soda may not be appropriate for all clients and should be based on individual preferences and needs.

Option c is incorrect because positioning the client supine in bed may not be comfortable for all clients and should be based on individual preferences and needs.

Option d is incorrect because suctioning the client's airway every hour may not be necessary and should be based on individual needs.

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A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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