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 B

Explanation

A. "I will gently restrain him during seizures."- Restraint during seizures can cause injury and is not recommended.
B. "I will loosen his clothing during seizures."- Loosening tight clothing helps prevent injury and ensures adequate ventilation during a seizure.
C. "I will insert a washcloth in his mouth during seizures."- Inserting objects into the mouth during a seizure can cause injury or obstruct the airway.

D. "I will turn him on his back during seizures."- Placing the client on their back during a seizure can increase the risk of aspiration. The recovery position is preferred

A. Hypocalcemia B. Hypermagnesemia C. Hyperkalemia D. Hypokalemia

Correct Answer is D

Explanation

A. Hypocalcemia- Vomiting and diarrhea can lead to fluid and electrolyte losses, but hypocalcemia is not a common finding in this scenario.
B. Hypermagnesemia- Hypermagnesemia is unlikely in the context of vomiting and diarrhea, as these conditions typically result in magnesium loss.
C. Hyperkalemia- Vomiting and diarrhea can lead to potassium loss, making hyperkalemia less likely.
D. Hypokalemia- Vomiting and diarrhea can cause potassium depletion, leading to hypokalemia. This electrolyte imbalance is commonly seen in clients with gastrointestinal losses.

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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 about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days, which of the following laboratory findings should the nurse expect?

Correct Answer is D

Explanation

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.)

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

A nurse is reviewing a client's electronic medical record (EMR). Which of the findings should the nurse identify as a risk factor for a potential accident or injury?

A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification and. Which of the following actions should the nurse take to verify the client's identity?

A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

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?

A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?

A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?