A nurse is preparing to provide tracheostomy care for a client.
Which of the following actions should the nurse plan to take?
Clean the stoma using an inward to outward circular motion.
Cleanse the inner cannula with isopropyl alcohol.
Ensure at least three finger widths of space under tracheostomy ties.
Prepare sterile supplies after removing the inner cannula.
The Correct Answer is A
a. Clean the stoma using an inward to outward circular motion.
When performing tracheostomy care, the nurse should clean the stoma from the inside outward in a circular motion. This technique reduces the risk of introducing pathogens to the stoma site by moving debris away from the incision rather than toward it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Believing that bad behavior is causing a sibling's death is a specific concern that some children may have.
Choice B Reason:
Believes that his brother's death will be reversible is incorrect. This is common among children wsho are 3-5 years old.
Choice C Reason:
Alienating oneself from peers can happen as a coping mechanism for some children, but it is not the expected response for all school-age siblings.
Choice D Reason:
Regressing to an earlier developmental level can occur in response to stress, but it is not the expected response for all school-age siblings and may not happen in every case.
Correct Answer is A
Explanation
Choice A Reason:
Determine the client's pattern for voiding. Understanding the client's current voiding pattern and habits is essential in developing a personalized bladder training plan. This information helps in identifying when and how often the client typically voids, which is crucial for planning the timing of toileting opportunities and other interventions.
Choice B Reason:
Assisting the client with relaxation techniques may be part of the bladder training program but is not the first step. First, you need to assess the client's current voiding pattern to establish a baseline.
Choice C Reason:
Discouraging intake of carbonated beverages may also be part of the plan, but it's not the initial step. Assessment and establishing a baseline come first.
Choice D Reason:
Offering toileting opportunities every 1 to 2 hours is a key component of bladder training, but before implementing this, you should assess the client's current voiding pattern to determine if these
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