A nurse is contributing to the plan of care for a client who had a tracheostomy placed 2 hr ago. Which of the following interventions should the nurse recommend for the plan of care?
Wear clean gloves when cleansing the tracheostomy site.
Cleanse the tracheostomy site with 0.9% sodium chloride.
Change the client's tracheostomy ties every 72 hr.
Suction the client's tracheostomy every 6 hr.
The Correct Answer is B
A. Wear clean gloves when cleansing the tracheostomy site.
Sterile gloves are required in the immediate post-op period to prevent infection.
B. Cleanse the tracheostomy site with 0.9% sodium chloride.
Isotonic saline is used for routine tracheostomy site cleansing to reduce infection risk.
C. Change the client's tracheostomy ties every 72 hr.
Ties should be changed as needed or per protocol, often more frequently in early post-op period.
D. Suction the client's tracheostomy every 6 hr.
Suction as needed, not on a fixed schedule, to avoid mucosal trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Delay admission while client fills out form
Admission should proceed; education about advance directives can occur during the process.
B. Confirm with family that consent was signed
Only the client can give informed consent unless they are unable and have a legal surrogate.
C. Determine if the client has prepared their advance directives.
Advance directives should be assessed upon admission to ensure client autonomy is respected.
D. Explain consent form prevents refusal of care
Clients can refuse care at any time, even after signing consent.
Correct Answer is B
Explanation
A. Determining whether the client has incisional pain:
This requires assessment and clinical judgment, which is the nurse’s responsibility.
B. Transferring the client from the bed to a chair:
This is a task-based, routine activity that can safely be delegated to an assistive personnel.
C. Checking the client's surgical dressing for bleeding:
Assessing a wound for signs of bleeding is a nursing task.
D. Showing the client how to use an incentive spirometer:
Teaching is a nursing responsibility, not within the AP’s scope of practice.
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