A nurse is preparing to perform tracheostomy care for a client. In which order should the nurse take the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Ensure a method to communicate during the procedure.

Wear clean gloves to remove the tracheostomy dressing.

Clean the inner cannula using a small brush.

Explain the procedure to the client.

Apply clean tracheostomy ties.

Answer and Explanation

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

D. Explain the procedure to the client. Before starting any procedure, explaining it to the client helps reduce anxiety and ensures cooperation. A. Ensure a method to communicate during the procedure. Since the client may have difficulty speaking, establishing a method of communication (such as hand signals or a writing board) is essential to ensure their comfort and safety during the procedure. B. Wear clean gloves to remove the tracheostomy dressing. Putting on clean gloves is important before touching the site and removing the dressing to prevent infection. C. Clean the inner cannula using a small brush. Cleaning the inner cannula is critical to prevent the buildup of secretions and ensure the airway remains clear. E. Apply clean tracheostomy ties. Once the site is cleaned and the cannula is secured, applying new, clean ties will ensure the tracheostomy tube remains in place and secure.

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Correct Answer is B

Explanation

Choice A Reason:
"Will use ibuprofen when I have a headache." This statement is inappropriate. Enoxaparin is an anticoagulant, and using nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can increase the risk of bleeding. So, using ibuprofen isn't recommended without consulting a healthcare professional while on enoxaparin.
Choice B Reason:
“Will use an electric razor for shaving.” This statement is correct. Enoxaparin is an anticoagulant, and using a sharp razor increases the risk of bleeding. Using an electric razor reduces the chance of nicks or cuts that could lead to bleeding complications while on this medication.
Choice C Reason:
“Will avoid the use of stool softeners." This statement is inappropriate. Enoxaparin doesn't directly interact with stool softeners. However, it's crucial to consult a healthcare provider before taking any new medications, including stool softeners, while on enoxaparin, as there might be potential interactions or effects on clotting.
Choice D Reason:
"I will massage the site after each injection." This statement is inappropriate. Massaging the site after an enoxaparin injection could potentially cause bruising or irritation. The usual recommendation is to apply gentle pressure at the injection site for a short time after the injection but not to massage it vigorously.

A. Wipe the sample port with an alcohol wipe and let the alcohol dry. B. Clamp the catheter tubing distal to the sampling port for 15 min. C. Attach a sterile needleless syringe to the sample port and aspirate the specimen D. Document in the client's electronic medical record that the specimen was sent to the laboratory. E. Empty the urine into a sterile container labeled with the client identifiers

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

Explanation

Clamp the catheter tubing distal to the sampling port for 15 min. By clamping the tubing distal to the sampling port, it allows urine to accumulate in the tubing, ensuring that the urine specimen obtained is fresh and not from the stagnant urine that has been sitting in the tubing.

Wipe the sample port with an alcohol wipe and let the alcohol dry. Cleaning the sampling port with an alcohol wipe helps reduce the risk of introducing contaminants into the sample during collection, ensuring a more sterile procedure.

Attach a sterile needleless syringe to the sample port and aspirate the specimen. Using a sterile syringe prevents contamination and allows for the collection of a clean urine sample directly from the catheter tubing, maintaining the sterility of the specimen.

Empty the urine into a sterile container labeled with the client identifiers. Transferring the collected urine into a sterile container labeled with the client's identifiers ensures proper identification and handling of the specimen for laboratory analysis.

Document in the client's electronic medical record that the specimen was sent to the laboratory. Documenting in the client's medical record ensures that there is a clear record of the specimen collection, its handling, and its dispatch to the laboratory for analysis, maintaining proper documentation and continuity of care.

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A nurse is preparing to perform tracheostomy care for a client. In which order should the nurse take 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 reinforcing teaching with a client who is taking enoxaparin. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

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

Explanation

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