A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage the tracheostomy at home? (Select all that apply.)
Obturator
Cotton balls
Oxygen tank
Pipe cleaners
Petroleum jelly
Correct Answer : A,C
Rationale:
A. The obturator is needed in case the tracheostomy tube becomes dislodged, allowing safe reinsertion.
B. Cotton balls should not be used near the tracheostomy because fibers can be inhaled and cause airway obstruction.
C. An oxygen tank may be required to ensure adequate oxygenation at home, especially if the client has respiratory compromise.
D. Pipe cleaners are unsafe for cleaning tracheostomy equipment because they can leave particles or cause trauma. Only sterile, manufacturer-approved cleaning devices should be used.
E. Petroleum jelly is not recommended because it can occlude the airway and increase infection risk; water-based lubricants are preferred if lubrication is necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Asking the son to leave allows the nurse to interview and assess the client privately. This ensures the client can speak freely about possible abuse without fear of intimidation.
B. Asking about injuries in the presence of the possible abuser may prevent the client from disclosing abuse and could place the client at further risk.
C. An incident report is for internal facility events (e.g., falls, medication errors), not for suspected abuse. Abuse must be reported to the appropriate authorities, not just documented internally.
D. Discharging the client without investigation puts the client at continued risk of harm and fails to meet the nurse’s legal obligation to protect vulnerable populations.
Correct Answer is A
Explanation
Rationale:
A. In emergency situations where the client is unable to provide informed consent (disoriented) and there is a life-threatening condition (cardiac arrhythmia), treatment should proceed under the principle of implied consent to save life or prevent serious harm.
B. Contacting next of kin may cause a delay in critical treatment and is not required in emergencies.
C. Notifying risk management is unnecessary and would delay care.
D. The client is disoriented and unable to legally sign consent, so this option is not appropriate.
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