A nurse is providing discharge teaching for the family of a client who had a tracheostomy inserted 2 months ago. Which of the following instructions should the nurse include?
"Use the clean technique when suctioning."
"Clean the stoma site with full-strength hydrogen peroxide."
"Decrease the humidity level in your home."
"Remove soiled tracheostomy ties before replacing them."
The Correct Answer is A
Rationale:
A. "Use the clean technique when suctioning.": For a well-established tracheostomy (typically after 1 month), clean technique is acceptable for suctioning at home. This reduces infection risk while allowing practical self-care or family-provided care in a non-sterile environment.
B. "Clean the stoma site with full-strength hydrogen peroxide.": Full-strength hydrogen peroxide is too harsh and can damage healthy tissue. A diluted solution or normal saline is safer for routine stoma care to avoid irritation and promote healing.
C. "Decrease the humidity level in your home.": Adequate humidity is essential for clients with tracheostomies to keep secretions thin and prevent airway blockage. Low humidity can dry the airway and increase the risk of mucus plugs.
D. "Remove soiled tracheostomy ties before replacing them.": Tracheostomy ties should be replaced one side at a time to prevent accidental decannulation. Removing both sides at once leaves the tracheostomy tube unsecured and poses a serious safety risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Increased pigmentation: Triamcinolone, a topical corticosteroid, is not known to cause increased skin pigmentation. In some cases, prolonged use can lead to hypopigmentation, especially in clients with darker skin tones.
B. Localized hair loss: Hair loss is not commonly associated with triamcinolone use. In fact, some corticosteroids may lead to localized hair growth due to their effects on the skin and follicles.
C. Thinning of the skin: Prolonged use of topical corticosteroids like triamcinolone can lead to skin atrophy. This manifests as thinning of the skin, increased fragility, and a higher risk of bruising or tearing with minimal trauma.
D. Increased sensitivity to the sun: Photosensitivity is not a typical side effect of triamcinolone. Sun protection is generally recommended for healthy skin care, but triamcinolone does not specifically increase sun sensitivity.
Correct Answer is D
Explanation
Rationale:
A. BUN 16 mg/dL (10 to 20 mg/dL): This is a normal blood urea nitrogen level and does not indicate dehydration or fluid volume deficit. Elevated BUN may suggest volume depletion, but this value is within the expected range.
B. Urine output 40 mL every hour for 3 hr: A urine output of 30 mL/hr or greater is considered adequate in most adult clients. Therefore, 40 mL/hr is within acceptable limits and does not suggest fluid volume deficit.
C. Hct 42% (37% to 47%): This hematocrit level falls within the normal range and does not indicate hemoconcentration. Elevated hematocrit could signal dehydration, but this value alone does not support that conclusion.
D. Surgical drain output 300 mL during an 8-hr shift: This is a significant amount of fluid loss postoperatively and can contribute to fluid volume deficit. High drain output following surgery, especially spinal procedures, increases the client's risk for hypovolemia and should be closely monitored.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.