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 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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Related Questions
Correct Answer is D
Explanation
After a tonic-clonic seizure, the nurse should first check the child for any injuries, particularly in the oral cavity. This is because during a seizure, the child's tongue may have been biten, or there may be other oral injuries. Therefore, it is essential to check the oral cavity for any injury or bleeding.
Offering sips of clear fluids is not a priority at this time as the child may still be disoriented and at risk of choking. Placing the child in a supine position is also not recommended because the child may have difficulty breathing due to muscle weakness or constriction of the airways. Administering an oral antiepileptic medication is not appropriate at this time unless prescribed by a healthcare provider.
Correct Answer is A
Explanation
This statement demonstrates an understanding that music therapy can help divert the client's attention from the pain they are experiencing, providing a distraction and potentially reducing their awareness of the pain. Music therapy is often used as a complementary approach to pain management in hospice care, aiming to improve the client's comfort and well-being.
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