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 C

Explanation

A) Tuna fish - Tuna fish is a source of animal protein and is not suitable for a lacto- vegetarian diet, which excludes meat but includes dairy.
B) Clam chowder - Clam chowder typically contains seafood and is not suitable for a lacto-vegetarian diet.
C) Cheese - Cheese is a dairy product and is suitable for a lacto-vegetarian diet, which includes dairy but excludes meat.
D) Chicken - Chicken is a source of animal protein and is not suitable for a lacto- vegetarian diet.

A. Obtain verbal consent from the client. B. Witness the client's signature on a consent form. C. Check the medical record for the client's signature on a previous consent form. D. Have another nurse co-sign the client's consent

Correct Answer is B

Explanation

A) Obtain verbal consent from the client. - While obtaining verbal consent is important, for invasive procedures like catheter insertion, it's essential to have written, witnessed consent to ensure proper documentation and confirmation that the client is fully informed and agrees to the procedure.
B) Witness the client's signature on a consent form. - Express consent for medical procedures typically involves the client signing a consent form after being adequately informed about the procedure, its potential risks, benefits, and alternatives. Witnessing the client's signature on a consent form ensures that the client has provided informed consent for the specific procedure.
C) Check the medical record for the client's signature on a previous consent form. - Consent for procedures should ideally be obtained for each specific instance, especially for invasive procedures.
D) Have another nurse co-sign the client's consent. - Co-signing consent is not necessary for minor procedures like urinary catheter insertion; verbal consent from the client is sufficient.

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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 caring for a client who follows a lacto-vegetarian diet. Which of the following food choices should the nurse recommend?

Correct Answer is C

Explanation

A nurse is preparing to insert an indwelling urinary catheter and is verifying the client's express consent for this procedure. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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