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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) To an employer for a pre-employment screening - Health information should not be disclosed to an employer without the client's written consent, as it violates the client's right to privacy and confidentiality.
B) To an insurance agency in regard to a life insurance policy - Health information should not be disclosed to an insurance agency without the client's written consent, as it violates the client's right to privacy and confidentiality.
C) To a family member when the client is not available - Health information should only be disclosed to family members with the client's written consent or in situations where it is necessary for the client's care or safety.
D) To a medical interpreter service on behalf of a client - Health information can be disclosed to a medical interpreter service without the client's written consent to facilitate communication between the client and healthcare providers while maintaining confidentiality.

A. Recheck the client's SaO2 level after having the client cough and clear their throat. B. Notify the charge nurse of the client's condition. C. Review the client's most recent SaO2 level in the medical record. D. Check the client's medical records to see which medications were recently admitted.

Correct Answer is A

Explanation

A) Recheck the client's SaO2 level after having the client cough and clear their throat.

- This action helps determine if the low SaO2 level is due to a transient cause such as mucus or secretions blocking the airway.
B) Notify the charge nurse of the client's condition. - While important, this action should come after assessing and addressing the client's immediate needs.
C) Review the client's most recent SaO2 level in the medical record. - This information may provide context but does not address the current low SaO2 level.
D) Check the client's medical records to see which medications were recently admitted. - Medications may contribute to respiratory issues, but addressing the client's immediate respiratory distress takes priority.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

Correct Answer is D

Explanation

A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SpO2 level is 88% while on room air. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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