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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Furosemide is a diuretic medication that helps remove excess fluid from the body by increasing urine production and output. In a client with heart failure, one of the indicators that the medication is effective is an increase in urinary output. This can help reduce fluid buildup in the body, which can improve symptoms of heart failure.
Correct Answer is B
Explanation
Before any invasive procedure, it is essential to ensure that the client has provided informed consent. Informed consent involves providing the client with information about the procedure, its risks, benefits, and alternatives, allowing them to make an informed decision about their healthcare. The nurse should verify that the client has been adequately informed about the esophagogastroduodenoscopy procedure and has given consent before proceeding.
Informing the client about the procedure duration of 60 minutes is not a priority action. While it is helpful to provide the client with information about the procedure, the specific duration of the procedure may vary depending on various factors, and it does not require immediate attention prior to the procedure.
Ensuring that the client's bladder is full is not necessary for an esophagogastroduodenoscopy procedure. The procedure involves examining the upper gastrointestinal tract and does not involve the bladder or urinary system.
Administering an oral contrast solution is not typically required for an esophagogastroduodenoscopy procedure. Oral contrast solutions are commonly used for other
diagnostic imaging procedures, such as computed tomography (CT) scans or barium studies, but not for esophagogastroduodenoscopy.
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