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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Correct Answer is C

Explanation

Emptying the drainage bag once a day is not frequent enough and could lead to overfilling and potential urinary tract infections.

Applying antiseptic ointment to the tip of the penis is not recommended as it can cause irritation and increase the risk of infection.

Keeping the drainage bag below the level of the waist helps prevent backflow of urine into the bladder and reduces the risk of infection.

Clamping the tube when going for a walk can cause urine to back up into the bladder and increase the risk of infection.

A. Respiratory therapist B. Speech-language pathologist C. Registered dietitian D. Occupational therapist

Correct Answer is B

Explanation

A. While a respiratory therapist may be involved in the care of a client with dysphagia, their primary focus is on respiratory function rather than swallowing difficulties.
B. A speech-language pathologist specializes in the assessment and treatment of swallowing disorders (dysphagia) and would be the most appropriate interprofessional team member to address this client's needs.

C. A registered dietitian may be involved in the client's care to provide guidance on appropriate nutrition and dietary modifications, but they do not typically specialize in the assessment and
treatment of dysphagia.
D. An occupational therapist may be involved in the client's care for other aspects of
rehabilitation, such as activities of daily living and upper extremity function, but they do not typically specialize in the assessment and treatment of dysphagia.

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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.)

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Correct Answer is B

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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.)

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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.)