48. 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.

Wipe the inside of the inner cannula with a folded pipe cleaner.

Cleanse the stoma site with 0.9% sodium chloride solution.

Answer and Explanation

The Correct Answer is A,B,C,D,E

Pouring 0.9% sodium chloride solution into the sterile basin provides the solution necessary for cleaning the inner cannula.

Unlocking and removing the inner cannula is the first step in the process of tracheostomy care.

Scrubbing the inside and outside of the inner cannula with a small brush helps remove secretions and debris.

Wiping the inside of the inner cannula with a folded pipe cleaner further cleans the inner surfaces.

Cleansing the stoma site with 0.9% sodium chloride solution completes the tracheostomy care procedure.

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

A. Squeezing the client's finger until a blood drop forms can result in hemolysis and inaccurate results; instead, gentle milking or massaging of the finger is recommended.
B. Applying clean gloves is necessary to maintain infection control practices.

C. Pricking the side of the client's finger is the appropriate technique for obtaining a capillary blood specimen.
D. Elevating the client's hand above the level of the heart is not necessary and may impede blood flow.

E. Cleansing the client's finger with an iodine swab helps to disinfect the area prior to obtaining the blood specimen.

A. The stoma bleeds lightly when touched. B. The stoma is draining a small amount of liquid stool. C. The stoma appears dark in color. D. The stoma protrudes slightly from the abdomen.

Correct Answer is C

Explanation

A. The stoma bleeds lightly when touched: Light bleeding is common postoperatively and may not be concerning unless it's excessive or persistent.
B. The stoma is draining a small amount of liquid stool: This is a normal finding following colostomy placement and is expected in the early postoperative period.
C. The stoma appears dark in color: This may indicate compromised blood supply to the stoma and requires immediate evaluation by the provider.
D. The stoma protrudes slightly from the abdomen: This is a normal finding post-colostomy and does not typically require immediate intervention.

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48. 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 preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

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48. 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.)