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

a. Clean the stoma using an inward to outward circular motion.

When providing tracheostomy care, the nurse should clean the stoma using an inward to outward circular motion to remove any secretions or debris. It is important to avoid using excessive force or pressure, which can cause trauma to the stoma. Cleansing the inner cannula with isopropyl alcohol may be appropriate for some clients, but it is important to follow the healthcare provider's orders regarding inner cannula care.

When securing the tracheostomy ties, the nurse should ensure that there is enough space for two fingers, not three. Finally, the nurse should prepare sterile supplies before removing the inner cannula to ensure that they are readily available and reduce the risk of infection.

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Correct Answer is C

Explanation

This situation involves a medication error that could potentially harm the client, and it should be reported through an incident report.

The following examples may not require an incident report:

A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.

A nurse observes a client vomiting after receiving an oral pain medication. While this situation should be assessed and managed appropriately, it does not necessarily warrant an incident report unless there are additional factors or complications involved.

A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. This situation may raise concerns regarding proper restraint removal techniques or potential safety issues, but it does not inherently indicate an immediate need for an incident report. However, if the nurse's actions were contrary to policy or posed a risk to the client's safety, it should be reported.

A. Assist the client to the orthopneic position. B. Instruct the client to remain as still as possible during the recording. C. Attach a blood pressure cuff to the client's upper arm. D. Tell the client to expect a mild stinging sensation during the test.

Correct Answer is B

Explanation

It is important for the client to remain still during the recording of a 12-lead ECG to obtain accurate and clear readings of the heart's electrical activity.

The orthopneic position (sitting upright and leaning forward) is typically used to help relieve shortness of breath in clients with respiratory distress and is not directly related to obtaining a 12-lead ECG.

Attaching a blood pressure cuff is not necessary for obtaining a 12-lead ECG, as it measures blood pressure and not the electrical activity of the heart.

A mild stinging sensation is not expected during the test. The electrodes used to record the ECG are typically adhesive and do not cause discomfort to the client

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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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Naxlex Comprehensive Predictor Exams

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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?