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 A
Explanation
When providing teaching about health promotion guidelines to a group of young adult male clients, the nurse should include the recommendation to have a dental examination every 6 months. Regular dental examinations can help prevent dental problems and maintain good oral health.
b) A testicular examination is recommended annually, not every 2 years.
c) A tetanus booster is recommended every 10 years, not every 5 years.
d) A herpes zoster immunization is recommended for adults age 60 and older, not age 50.
Correct Answer is C
Explanation
The nurse should assist the client with a bowel cleansing before an intravenous pyelogram. This helps to ensure that the bowel is empty and that the images obtained during the procedure are clear. The other
a. Oral contrast is not typically used for an intravenous pyelogram.
b. Pain in the suprapubic region is not a common side effect of an intravenous pyelogram.
d. Removing metal objects is important for procedures that use magnetic resonance imaging (MRI), but it is not necessary for an intravenous pyelogram.
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