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

Allow space for one finger to be placed under the tube ties.

Apply suction pressure while inserting the catheter into the trachea.

Suction the client for 20 seconds with each pass.

Cleanse around the stoma with povidone-iodine.

Answer and Explanation

The Correct Answer is A

Choice A reason: Allowing space for one finger to be placed under the tube ties is a correct action for tracheostomy care. This ensures that the tube ties are not too tight, which can cause skin breakdown, pressure necrosis, or impaired circulation. The tube ties should also not be too loose, which can cause accidental dislodgement of the tube.

Choice B reason: Applying suction pressure while inserting the catheter into the trachea is an incorrect action for tracheostomy care. This can cause trauma to the tracheal mucosa and increase the risk of infection and bleeding. The nurse should apply suction pressure only while withdrawing the catheter and rotate it gently to remove secretions.

Choice C reason: Suctioning the client for 20 seconds with each pass is an incorrect action for tracheostomy care. This can cause hypoxia, bradycardia, or cardiac arrest due to vagal stimulation. The nurse should suction the client for no more than 10 to 15 seconds with each pass and allow at least 30 seconds between passes for oxygenation.

Choice D reason: Cleansing around the stoma with povidone-iodine is an incorrect action for tracheostomy care. Povidone-iodine is a strong antiseptic that can irritate the skin and cause allergic reactions. The nurse should cleanse around the stoma with normal saline or sterile water and apply a thin layer of water-soluble lubricant to protect the skin.

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Correct Answer is D

Explanation

Choice A reason: Potassium 4.0 mEq/L is a normal value for serum potassium. Potassium is an electrolyte that regulates nerve and muscle function, cardiac rhythm, and fluid balance. Abnormal levels of potassium can indicate renal dysfunction, dehydration, or acid-base imbalance, but not heart failure.

Choice B reason: Calcium 9.0 mg/dL is a normal value for serum calcium. Calcium is an electrolyte that regulates bone health, muscle contraction, blood clotting, and nerve transmission. Abnormal levels of calcium can indicate parathyroid dysfunction, vitamin D deficiency, or malignancy, but not heart failure.

Choice C reason: Sodium 140 mEq/L is a normal value for serum sodium. Sodium is an electrolyte that regulates fluid balance, blood pressure, and nerve and muscle function. Abnormal levels of sodium can indicate dehydration, fluid overload, or hormonal imbalance, but not heart failure.

Choice D reason: Brain natriuretic peptide (BNP) 275 pg/mL is an elevated value for serum BNP. BNP is a hormone that is released by the heart when it is stretched or stressed due to increased pressure or volume overload. BNP causes diuresis, vasodilation, and decreased blood pressure to reduce the workload of the heart. Elevated levels of BNP indicate heart failure, which means that the heart cannot pump enough blood to meet the body's needs.

A. Use safety pins to secure the pad in place. B. Cover the pad prior to use. C. Apply the pad for 45 minutes at a time. D. Fill the pad with sterile water.

Correct Answer is B

Explanation

Choice A reason: This is not an appropriate action because using safety pins to secure the pad in place can puncture or damage the pad and cause leakage or malfunction. The nurse should use Velcro straps or tape to secure the pad in place.

Choice B reason: This is an appropriate action because covering the pad prior to use can prevent direct contact between the pad and the skin and reduce the risk of burns or irritation. The nurse should use a clean towel or sheet to cover the pad.

Choice C reason: This is not an appropriate action because applying the pad for 45 minutes at a time can cause tissue damage or necrosis due to prolonged exposure to heat. The nurse should apply the pad for no more than 20 minutes at a time and check the skin condition frequently.

Choice D reason: This is not an appropriate action because filling the pad with sterile water can increase the cost and waste of resources without any benefit. The nurse should fill the pad with tap water as instructed by the manufacturer.

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