A client is being weaned from a tracheostomy tube and has tolerated capping of the tube for 24 hours. Which action by the nurse is most appropriate?
a. Collect all materials needed for suturing the stoma shut.
b. Place a dry dressing over the stoma and tape it securely.
c. Assess the client for air leaking around the tube.
d. Select a smaller tracheostomy tube to be inserted.
B
The tube will be able to be removed after the client has tolerated capping of it for 24 hours. Therefore, a dry dressing will be able to be placed over the stoma. The stoma will not be sutured. It will heal on its own with a small scar. Airflow should be adequate around the capped tube. The physician will not likely insert the next smallest size tube but instead will remove the existing tube.
You might also like to view...
During the first 30 to 60 minutes after birth, which attachment takes place between parent and child?
a. bonding c. engrossment b. claiming d. entrainment
The nurse is planning care for a patient recovering from bladder neck surgery. What should the nurse include in this patient's plan of care?
Select all that apply. 1. securing urinary catheters in position 2. reporting any onset of bright red urine 3. measuring urine output and reporting changes 4. gently tugging on urinary catheter every shift 5. expecting urine to be pink and gradually clear
The nurse concludes that a young adult client is completing developmental tasks within Havighurst's early adulthood age period. What did the nurse assess to come to this conclusion?
1. Taking on civic responsibility 2. Developing adult leisure-time activities 3. Getting started in an occupation 4. Relating oneself to one's spouse as a person 5. Managing a home
The nurse is caring for a patient who has a diagnosis that she is not familiar with. The nurse uses reference materials and does a literature search to better understand the diagnosis
The nurse then utilizes this knowledge, along with the nurse's experience and patient preferences, to develop a plan of care. This is an example of the nurse using _____ to provide care for her patient. a. Evidence-based practice b. Research-based practice c. Applied quality improvement d. Nursing informatics