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) "I'm glad to have the opportunity to choose what kind of care I receive while I still can." - This statement reflects an understanding of the purpose of advance directives, which is to allow individuals to express their wishes for care while they are still able to do so.
B) "If I want life support, I'll need to sign a separate consent form first." - This statement does not accurately reflect the purpose or process of advance directives.
C) "I can't change my mind about the care I will receive once I sign my living will." - Advance directives can be updated or revoked at any time as long as the individual is of sound mind and able to make decisions.
D) "Once I fill out my living will, there will be a 1-month delay before it is legally binding." - Advance directives typically become legally effective as soon as they are completed and signed, without a waiting period.
Correct Answer is D
Explanation
A. “I’ll keep the height of my walker adjusted so lean slightly forward,”- Leaning slightly forward can compromise balance and stability, increasing the risk of falls.
B. “I’ll slide the walker and move it about a foot in front of me.”- Sliding the walker too far ahead can lead to instability and loss of balance.
C. “I’ll move the walker and my stronger leg ahead at the same time- The walker should be moved one step ahead followed by the weaker leg, which should be placed in the middle of the walker.
D. “I’ll keep my elbows slightly bent when I grasp the walker"- Keeping the elbows slightly bent is a general instruction for using a walker which ensures proper posture and balance.
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