The nursing student is performing tracheostomy care on a client. Which action by the student leads the supervising nurse to intervene?
a. Using folded gauze dressings on both sides of the stoma
b. Cutting a slit in a gauze 4 ? 4 pad to fit around the stoma
c. Applying new tracheostomy ties before removing old ones
d. Tying the twill tape in a square knot on the side of the neck
B
Tracheostomy dressings should be made from gauze pads with a manufactured slit in them that fits around the tube. If none are available, use two gauze pads folded in half placed on either side of the tube. Cutting a piece of gauze could result in entry of tiny shreds of the gauze the tracheostomy. The other interventions are appropriate.
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