A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

A. Lubricate the catheter with water-soluble gel.
Lubrication is important to reduce urethral trauma, but this is not the first step once the sterile field is prepared. It comes after draping and cleansing, just before catheter insertion.

B. Position the sterile drape leaving the perineum exposed.
This is the first action after donning sterile gloves and preparing the field. Draping maintains a sterile environment and provides access to the insertion site. Ensuring sterility from the beginning is critical for preventing catheter-associated infections.

C. Cleanse the client’s meatus with antiseptic solution.
Cleansing the meatus is done after draping to reduce the risk of introducing microorganisms during catheter insertion. Although essential, it is not the very first step once the sterile procedure begins.

D. Attach a prefilled syringe to the catheter inflation hub.
The balloon should not be prepared or inflated until after the catheter has been inserted and urine return is observed. Attaching the syringe too early may risk accidental inflation outside the bladder.

Answer: D

Rationale:

A. The American Hospital Association requires accredited facilities to have protocols in place requiring medication reconciliation: The American Hospital Association does advocate for medication reconciliation as part of safety protocols, but the primary focus of medication reconciliation is not solely based on AHA requirements. It is more about improving patient safety and preventing errors.

B. The nurse who performs medication reconciliation is demonstrating the ethical principle of veracity: While medication reconciliation involves accurate and truthful communication, it primarily serves to ensure safety and accuracy in medication management rather than directly demonstrating the ethical principle of veracity.

C. The International Council of Nurses Code of Ethics stipulates that the nurse performs medication reconciliation when a client is admitted to a facility, is transferred to another facility, and when a client is discharged from a facility: Although medication reconciliation is crucial at these points of care transition, the International Council of Nurses Code of Ethics does not explicitly mandate this process.

D. The purpose of medication reconciliation is to prevent adverse medication reactions: Medication reconciliation aims to ensure accurate medication lists and prevent errors, which in turn helps prevent adverse medication reactions. This aligns with the primary goal of the process, which is to enhance medication safety.