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 B
Explanation
Choice A Reason:
Decreased BUN (blood urea nitrogen) level is incorrect. While furosemide can lead to decreased BUN levels, it is not the primary indicator of its effectiveness. BUN levels can be influenced by various factors, including hydration status and kidney function.
Choice B Reason:
Increased urinary output is correct. Furosemide is a diuretic medication often prescribed to clients with heart failure to help manage fluid retention. One of the primary therapeutic effects of furosemide is increased urinary output, which indicates that the medication is effectively removing excess fluid from the body.
Choice C Reason:
Decreased hemoglobin level is incorrect. Furosemide is not directly associated with changes in hemoglobin levels. Hemoglobin levels reflect the oxygen-carrying capacity of the blood and are typically not affected by diuretic therapy.
Choice D Reason:
Increased weight of 0.91 kg (2 lb.) is incorrect. An increase in weight is not indicative of the medication's effectiveness. In fact, weight gain could be a sign of fluid retention and heart failure exacerbation, which would suggest that the medication may not be working optimally.
Correct Answer is D
Explanation
Choice A Reason:
The client wanting to talk about the diagnosis with nursing staff indicates a desire for communication and support, which may be an expression of hope or a way to cope with the diagnosis.
Choice B Reason:
Requesting a second opinion suggests that the client is actively seeking more information and exploring potential treatment options, which is not indicative of hopelessness.
Choice C Reason:
Having a decreased energy level can be a common physical and emotional response to a terminal illness but does not directly indicate hopelessness on its own. It may reflect the physical and emotional toll of the diagnosis and its treatment.
Choice D Reason:
The client makes funeral arrangements is correct. Making funeral arrangements is often seen as an indication of hopelessness in the context of a recent terminal illness diagnosis. It suggests that the client has accepted the inevitability of their death and is preparing for it. While making arrangements can be a practical and important step, it may also indicate a sense of hopelessness or resignation.
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