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.

Answer and Explanation

The Correct Answer is A

The correct answer is: a. Clean the stoma using an inward to outward circular motion.

Title: Choice A reason: Cleaning the stoma with an inward to outward circular motion is a recommended practice to prevent infection and ensure that any debris or secretions are cleared away from the tracheostomy site. This method helps to minimize the risk of introducing pathogens directly into the stoma and is considered a best practice in tracheostomy care.

Title: Choice B reason: Cleansing the inner cannula with isopropyl alcohol is not recommended because it can cause irritation to the tracheal mucosa. Instead, sterile saline is typically used for cleaning the inner cannula to avoid any potential damage to the tracheal tissues and to maintain a safe and comfortable environment for the patient.

Title: Choice C reason: Ensuring at least three finger widths of space under tracheostomy ties is not the standard practice. The recommended space is to allow one to two finger widths under the tracheostomy ties to ensure they are secure but not too tight, which could lead to skin breakdown or discomfort for the patient.

Title: Choice D reason: Preparing sterile supplies should be done before removing the inner cannula, not after. This is to ensure that all necessary supplies are ready to use immediately after the inner cannula is removed, minimizing the time the stoma is open and reducing the risk of infection.

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Correct Answer is C

Explanation

Using a cool-mist vaporizer in the baby's room can help provide moisture and relieve nasal congestion, especially during cold or dry weather. It can help ease breathing and improve the baby's comfort.

"I will leave the plastic covering on the crib mattress": This statement is incorrect. The plastic covering should be removed from the crib mattress before placing the baby in the crib. The plastic covering poses a suffocation risk and should not be used.

"I will lay my baby's head on a pillow while he is in the crib": This statement is incorrect. Pillows should not be used in the crib for infants. They increase the risk of suffocation and can pose a hazard to the baby. The crib should be free of pillows, blankets, stuffed animals, or any other loose items.

"I will leave my baby's bib on while he is sleeping": This statement is incorrect. Bibs should be removed before placing the baby in the crib or while the baby is sleeping to prevent the risk of suffocation. Loose items around the baby's neck can pose a strangulation hazard.

A. Use hydrogen peroxide for wound cleaning. B. Perform dressing changes every other day. C. Cleanse the most contaminated wounds first, D. Apply dressings with sterile gloves.

Correct Answer is D

Explanation

A.Using hydrogen peroxide for wound cleaning is not recommended as it can cause tissue damage and delay healing.

B.Burn dressings should typically be changed more frequently, often at least once per day, depending on the type and severity of the burn and the type of dressing used.Delaying dressing changes could increase the risk of infection.
C.In wound care, the nurse should cleanse the least contaminated wounds first to prevent spreading microorganisms from more contaminated areas to cleaner areas. This reduces the risk of cross-contamination and infection. For burns, starting with the cleanest areas ensures a safer wound management process.

D.Applying dressings with sterile gloves is essential to maintain a sterile environment and reduce the risk of infection, especially in clients with burns who are at high risk for infection due to compromised skin integrity.

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A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

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