Nokea
A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy?
- A. I must carry tissues with me.
- B. I must give up my love of pool aerobics.
- C. I will not be able to have the tracheostomy removed.
- D. Tell my spouse about it, I do not want to touch it.
Correct Answer: D
Rationale: Not wanting to participate in care and diverting the care to others indicates that the client has not accepted the tracheostomy. When evaluating teaching, the nurse should assess client and caregiver ability to provide home care. It is correct to carry tissues with the client because new tracheostomy tubes produce much mucous due to the irritation of the tube in the throat. Consideration needs to be arranged but being in a swimming pool may be completed as long as water does not surround the new tracheostomy. Stating the reality of not being able to remove the tracheostomy provides data that the client is accepting the tracheostomy as part of life.
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The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?
- A. Administer an over-the-counter decongestant.
- B. Use an anti-allergy medication to decrease rhinitis.
- C. Place a warm cloth over the sinus area of the forehead.
- D. Gently blow the nose to eliminate nasal secretions.
Correct Answer: A
Rationale: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opensthe nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best.
A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?
- A. Apply a moustache dressing.
- B. Provide a nasal splint.
- C. Apply direct continuous pressure.
- D. Place the client in a semi-Fowler's position.
Correct Answer: C
Rationale: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.
The nurse is caring for a client who is status post nasal polypectomy. What would the nurse instruct this client to report?
- A. Excessive swallowing
- B. Nasal stuffiness
- C. Diarrhea
- D. Coughing
Correct Answer: A
Rationale: The nurse inspects the nasal packing and dressings frequently for bleeding and asks the client to report excessive swallowing, which can indicate bleeding. Nasal stuffiness and diarrhea do not indicate postoperative bleeding. Coughing can loosen or expel scabs on the surgical wounds.
A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first?
- A. Call for the registered nurse to reinsert the tube.
- B. Place a dilator in the stoma to maintain the opening.
- C. Cover the tracheostomy site with a sterile gauze to prevent infection.
- D. Transfer the client to the emergency department.
Correct Answer: B
Rationale: If the tracheostomy tube becomes dislodged, a dilator is initially placed to hold the edges of the stoma apart until a physician is able to reinsert the tube. A tracheal tube must never be forced back into place. Covering the tracheostomy sitewith gauze can obstruct the stoma, decreasing ventilation. If needed, transporting the client to the emergency department may occur but not until the airway is stabilized.
The nurse is providing tracheostomy care for a client. Place the following steps in the order the nurse should perform them.
- A. Position client in a supine or low Fowler position.
- B. Using a clean glove, remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle.
- C. Open the tracheostomy kit without contaminating the contents. Don sterile gloves- keep the dominant hand sterile. Pour hydrogen peroxide and normal saline into respective containers.
- D. Unlock the inner cannula by turning it counterclockwise. Remove it and place in hydrogen peroxide. Clean the inside and outside of the cannula with pipe cleaners.
- E. Rinse the cleaned cannula with normal saline. Tap the cannula and wipe the excess solution with sterile gauze.
- F. Replace the inner cannula and turn it clockwise within the outer cannula.
- G. Clean around the stoma with an applicator moistened with normal saline.
Correct Answer: C,A,B,D,E,G,F
Rationale: The nurse should position client in a supine or low Fowler position. Using a clean glove, the nurse should remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle. The nurse should then open the tracheostomy kit without contaminating the contents. The nurse should don sterile gloves, keeping the dominant hand sterile. Next, the nurse should pour hydrogen peroxide and normalsaline into respective containers. The nurse should then unlock the inner cannula by turning it counterclockwise, afterward removing it and placing it in hydrogen peroxide. The nurse should clean the inside and outside of the cannula with pipe cleaners. Next, the nurse should rinse the cleaned cannula with normal saline. The nurse should then tap the cannula and wipe the excess solution with sterile gauze. Next, the nurse should replace the inner cannula and turn it clockwise within the outer cannula. The nurseshould then clean around the stoma with an applicator moistened with normal saline.Next, the nurse should place a sterile dressing around the tracheostomy tube andchange the tracheostomy ties by placing the new ones on first and removing the soiled ones last. Finally, the nurse should tie the new ends securely, but not tightly, at theside of the neck. The nurse should perform hand hygiene before, during, and after the procedure.