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

The nurse should provide written materials in the client's primary language for a client who requires teaching prior to discharge. This ensures that the client has access to important information in a language they understand and can refer to after leaving the facility.

b. A client who is watching a video about meal services in their primary language may not require additional written materials.

c. A client who is learning to use an incentive spirometer with the help of an interpreter may not require additional written materials.

d. The administration of a prescribed pain medication does not necessarily require the provision of written materials.

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

A nurse is caring for a group of clients whose primary languages are diﬀerent from the nurse's. For which of the following clients should the nurse provide written materials in the client's primary language?

Correct Answer is A

Explanation

A nurse is providing end-of-life care for a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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