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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is that the nurse should expect to find reduced sweat production when performing a skin assessment on an older adult client. As we age, our skin gradually loses its ability to produce sweat and oil, which can result in dry skin¹.
Options a, c and d are not expected findings when performing a skin assessment on an older adult client. Increased skin elasticity, increased production of oils and thickened outer layer of skin are not typical age- related changes.
Correct Answer is ["480"]
Explanation
480 mL.
The client's total oral intake over the 4-hour period is 3 ounces of milk + 2 ounces of orange juice + 3 ounces of tea + 4 ounces of water = 12 ounces. Since there are approximately 30 mL in 1 ounce, the client's oral intake in mL is 12 ounces * 30 mL/ounce = 360 mL.
The client is also receiving dextrose 5% in 0.45% sodium chloride at a rate of 30 mL/hr by continuous IV infusion. Over a 4-hour period, the client will receive a total of 30 mL/hr * 4 hours = 120 mL from the IV infusion.
Therefore, the client's total intake for that 4-hour period is 360 mL (oral intake. + 120 mL (IV infusion) = 480 mL.
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