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 B
Explanation
A. Obtain urine from the drainage bag if a urinary specimen is required- Urine specimens should be collected from the catheter port using a sterile technique, not from the drainage bag.
B. Use a catheter securing device to hold the catheter in place- A catheter securing device helps prevent movement or accidental removal of the catheter, reducing the risk of trauma or dislodgment.
C. Change the catheter bag every 3 days and as needed- Catheter bags should be changed according to facility policy or if they become soiled, not necessarily every 3 days.
D. Position the drainage bag higher than the client's bladder- The drainage bag should be positioned lower than the client's bladder to facilitate urine drainage by gravity and prevent reflux into the bladder.
Correct Answer is A
Explanation
A) Determine if the client has a support system. - Assessing the client's current support network is essential to determine available resources and potential interventions.
B) Schedule a mental health consult for the client. - While mental health support may be necessary, understanding the client's existing support system is the first step.
C) Provide the client with information about coping strategies. - Providing coping strategies is important but should come after assessing the client's support system.
D) Encourage the client to attend a support group. - Encouraging attendance at support groups can be helpful, but it's important to assess the client's current support system first.
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