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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not a statement that indicates acceptance, but rather denial or grief. The client is expressing a desire to return to their previous state and ignoring the reality of their situation. The nurse should acknowledge the client's feelings and provide emotional support and education.
Choice B reason: This is not a statement that indicates acceptance, but rather unrealistic or magical thinking. The client is expecting an impossible outcome and avoiding the facts of their condition. The nurse should explain the function and care of the ileostomy and clarify any misconceptions.
Choice C reason: This is a statement that indicates acceptance, as well as coping and resilience. The client is demonstrating a willingness to adapt to their new situation and seek help from others who have similar experiences. The nurse should praise the client's positive attitude and provide information and resources about support groups.
Choice D reason: This is not a statement that indicates acceptance, but rather avoidance or dependency. The client is showing a lack of interest or involvement in their self-care and relying on their partner to perform the tasks for them. The nurse should encourage the client's participation and independence and teach them how to empty and change the bag.
Correct Answer is A
Explanation
Choice A reason: This is an accurate information because moderate sedation, also known as conscious sedation, is a type of anesthesia that reduces anxiety and pain during the colonoscopy without causing loss of consciousness. The nurse should inform the client that they will need someone to drive them home after the procedure and that they may experience some drowsiness, nausea, or sore throat.
Choice B reason: This is not an accurate information because the client should drink only clear liquids, such as water, tea, broth, or juice, until 4 hours before the procedure. Full liquids, such as milk, cream, or soup, can interfere with the bowel preparation and obscure the visibility of the colon.
Choice C reason: This is not an accurate information because the client should drink the liquid bowel preparation as prescribed by the provider, usually cold or at room temperature. Warming the liquid bowel preparation may alter its effectiveness and taste.
Choice D reason: This is not an accurate information because the client will lie on their left side for the procedure, not on their right side. Lying on the left side allows better access and visualization of the colon by the endoscope.
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