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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Candidiasis, also known as a yeast infection, commonly presents with symptoms such as a thick, white vaginal discharge. It may also be accompanied by itching, redness, and irritation in the vaginal area. This type of discharge is typically described as resembling cottage cheese in texture. Other symptoms that may occur with candidiasis include burning during urination and discomfort during sexual intercourse.
A hard, painless chancre is a characteristic finding of syphilis, not candidiasis. Frothy, malodorous discharge is commonly associated with bacterial vaginosis, not candidiasis.
Feeling of pelvic heaviness is more commonly associated with conditions like pelvic organ prolapse or uterine fibroids, and is not specific to candidiasis.
Correct Answer is C
Explanation
Bacterial meningitis is a serious infection of the membranes surrounding the brain and spinal cord that can cause inflammation and damage to the nervous system.
Nuchal rigidity refers to stiffness and pain in the neck that makes it difficult to flex the neck forward. This finding is indicative of inflammation of the meninges and is a classic sign of meningitis.
Pedal edema refers to swelling of the feet and ankles and can be caused by various conditions such as heart, liver, or kidney problems.
Jaundice refers to yellowing of the skin and eyes and can be caused by liver or bile duct disease.
Hematuria refers to the presence of blood in the urine and can be caused by various conditions such as urinary tract infections, kidney stones, or bladder cancer. These findings are not related to bacterial meningitis and may suggest other health concerns that require further evaluation and management.
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