The student nurse is providing tracheostomy care to a patient who has intratracheal secretions and a damp tracheostomy dressing and ties. Which action by the student should the nursing instructor question?
a. Suctioning the tracheostomy tube before removing the soiled tracheostomy dressing
b. Assisting the patient to semi-Fowler's position
c. Placing new tracheostomy ties before cutting the old ties
d. Cutting gauze pads to place around the tracheostomy tube
D
Do not use scissors to cut gauze pads as they may shed fibers that could be inhaled by the patient. Use a manufactured pad with a slit. Suctioning the tube removes secretions to avoid occluding the outer cannula while the inner cannula is removed. Usually a supine or semi-Fowler's position is used to promote patient comfort and prevent muscle strain for the nurse. If changing ties without an assistant, the old ties are not cut until the new ties are securely in place.
You might also like to view...
Which would be the most effective way for nursing to improve the power of its image?
1. All nurses becoming politically active 2. Dressing, speaking, and acting in a professional manner 3. Motivating others to become nurses 4. Encouraging clients to speak positively about their encounters with nurses
Thrombolytic therapy is being prepared for administration to an older adult patient who has presented to the emergency department with an ST-segment elevation MI (STEMI). The nurse recognizes that the primary goal of this intervention is:
A) To restore the flow of blood through the coronary arteries B) To restore function to infarcted myocardial cells C) To relieve the patient's symptoms of chest pain and dyspnea D) To prevent the rupture of atheromas
The nurse is counseling a client who is trying to stop smoking. The nurse helps this client move through which of the following stages of behavioral change regarding smoking cessation?
1. precontemplation, contemplation, preparation, action, and maintenance 2. precontemplation, contemplation, preparation, announcement, and maintenance 3. precontemplation, contemplation, programming, announcement, and maintenance 4. precontemplation, contemplation, programming, action, and maintenance
A client with an inflamed appendix is feeling pain in the stomach area. What is the term for this body response to stress?
A) Local adaptation syndrome B) General adaptation syndrome C) Physiological homeostasis D) Fight-or-flight response