13. A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Unlock and remove the inner cannula.
Scrub the inside and outside of the inner cannula with a small brush.
Cleanse the stoma site with 0.9% sodium chloride solution.
Wipe the inside of the inner cannula with a folded pipe cleaner.
The Correct Answer is A,B,C,E,D
Correct Order of Steps: A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin. This step ensures the nurse has a sterile solution ready for cleaning the cannula and stoma site. B. Unlock and remove the inner cannula. Removing the inner cannula is necessary to clean it and prevent the buildup of secretions. C. Scrub the inside and outside of the inner cannula with a small brush. Cleaning the cannula thoroughly removes debris and secretions. E. Wipe the inside of the inner cannula with a folded pipe cleaner. The pipe cleaner is used to dry and clear any residual moisture or secretions inside the cannula. D. Cleanse the stoma site with 0.9% sodium chloride solution. Cleansing the stoma site is essential to maintain skin integrity and prevent infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Placing the restraint across the client's chest - This is not a safe practice since it can restrict breathing increasing the risk of asphyxiation.
B) Applying the restraint over the client's gown - Restraints should be applied over the clients gown and not directly to the client's skin to prevent friction and skin breakdown.
C) Using a quick-release tie to secure the restraint - Quick-release ties are important for ensuring that restraints can be quickly removed in case of an emergency.
D) Tying the restraint to the bed frame – Tying restraints on the bed frame is the recommended practice. Restraints should not be tied on the bed rails to avoid injuries if the side rails are released.
Correct Answer is A
Explanation
A) Place an identification tag on the outside of the client's shroud. - This is an important step in maintaining proper identification of the deceased individual.
B) Remove the client's dentures and give them to the client's family. - Dentures should be left in place unless requested by the family, as they are considered part of the deceased individual's personal belongings.
C) Wear sterile gloves when cleaning the client's body. - Sterile gloves are not necessary for postmortem care unless there are specific infection control concerns.
D) Ask the assistive personnel to document the client's time of death. - Documenting the time of death is typically the responsibility of the nurse or provider, not the assistive personnel.
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