Difficulty: Medium
Average Score: 90%
Simulated
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?
Correct answer
C
Rationale
The correct answer is C: Clean the stoma using an inward to outward circular motion. This action helps prevent contamination of the stoma and reduces the risk of infection. Cleaning in an inward to outward motion avoids pushing debris into the stoma.
A: Cleansing the inner cannula with isopropyl alcohol is not recommended as it can cause irritation to the client's airway.
B: Preparing sterile supplies after removing the inner cannula can lead to contamination and delay in providing care.
D: Ensuring at least three finger widths of space under tracheostomy ties is important for proper fit but is not directly related to tracheostomy care.
A: Cleansing the inner cannula with isopropyl alcohol is not recommended as it can cause irritation to the client's airway.
B: Preparing sterile supplies after removing the inner cannula can lead to contamination and delay in providing care.
D: Ensuring at least three finger widths of space under tracheostomy ties is important for proper fit but is not directly related to tracheostomy care.