The nurse is documenting the completion of tracheostomy suctioning and tracheostomy care in a client's medical record. What should this documentation include?

1. Lung sounds before and after suctioning
2. Characteristics of suctioned sputum
3. Integrity of the skin around the stoma
4. Side on which the tracheostomy tie knot is located
5. Flow rate of oxygen


Correct Answer: 1, 2, 3, 5
Rationale 1: The nurse should document lung sounds before and after suctioning.
Rationale 2: The nurse should document the characteristics of the suctioned sputum.
Rationale 3: The nurse should document the integrity of the skin around the stoma.
Rationale 4: The nurse does not need to document the side on which the tracheostomy tie knot is located.
Rationale 5: The flow rate of the oxygen is not a part of documentation after tracheostomy suctioning or tracheostomy care.

Nursing

You might also like to view...

When a nursing interview identifies that a client is daily taking doses of herbal supplements, the nurse's priority is to:

a. evaluate the effectiveness of the herbal supplement self-treatment. b. determine why the client feels the need to take the herbal supplements. c. identify when the herbal supplementation began. d. discuss the client's knowledge regarding the herbal supplements' side effects.

Nursing

The Rovsing's sign and iliopsoas muscle test are useful to determine the presence of:

A) Appendicitis. B) Cholecystitis. C) Duodenal ulcer. D) Hepatomegaly.

Nursing

A school-age child receives a small, superficial burn. Which action would be the most appropriate for the nurse to do first?

A) Apply a topical anesthetic ointment B) Administer acetaminophen C) Cover the area with a sterile bandage D) Apply cold compresses to the area

Nursing

A patient has an IV in her left arm. Which is correct?

a. Blood pressure is measured on the right arm. b. Blood pressure is measured on the left arm. c. She decides which arm to use. d. You use the arm that is easiest to reach.

Nursing