NCLEX-PN® ExaminationBasic Care and ComfortHard
A client with a new Tracheostomy is being taught about tracheostomy care. The LPN observes the client attempting to clean the inner cannula with hydrogen peroxide. Which immediate action should the LPN take?
- AAssess the client's respiratory status and stoma site.
- BProvide a clean tracheostomy care kit to the client.
- CInstruct the client to use normal saline instead of hydrogen peroxide.
- DDocument the client's attempt at self-care in the chart.
Show answer & explanationAnswer & explanation
Correct answer: C. Instruct the client to use normal saline instead of hydrogen peroxide.
Hydrogen peroxide can be irritating to the delicate mucous membranes of the tracheostomy and can delay healing. The LPN's immediate priority is to correct the unsafe technique by instructing the client to use normal saline, which is a safer and recommended solution for cleaning the inner cannula.
Why the other options are wrong
- A. Assessing respiratory status and stoma site is part of ongoing care but does not address the immediate unsafe action of using an inappropriate cleaning solution.
- B. Providing a clean kit is important for aseptic technique but does not immediately correct the unsafe cleaning solution being used.
- D. Documentation is essential but is not the immediate priority when an unsafe practice is observed.
Tracheostomy Care Solutions
Proper tracheostomy care involves using appropriate, non-irritating solutions to clean the stoma and inner cannula, ensuring airway patency and preventing infection or tissue damage.
- Normal saline is the preferred cleaning solution.
- Avoid irritating substances like hydrogen peroxide.
- Aseptic technique is crucial.
Memory trick: Saline Safe, Peroxide Peril.