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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"I will apply heat to my affected ankle to decrease swelling." Heat application is generally not recommended for acute injuries like ankle sprains. Heat can increase blood flow and potentially worsen swelling. Cold therapy (like ice) is typically advised in the early stages to reduce inflammation and swelling.
Choice B Reason:
"I can bear full weight on my affected ankle." For a grade 2 ankle sprain, bearing full weight on the affected ankle might not be advisable initially. Grade 2 sprains involve partial tearing of ligaments and usually require some period of rest or limited weight-bearing to allow healing.
Choice C Reason:
"I can dangle my affected ankle from the edge of the bed. “Dangling the affected ankle from the edge of the bed is a common recommendation to help with gentle movement and improve blood flow without putting excessive stress on the injured ankle. This activity can aid in the recovery process and is often recommended.
Choice D Reason:
"I will wrap my affected ankle with an elastic bandage. “Wrapping the affected ankle with an elastic bandage is a supportive measure recommended for managing ankle sprains. It helps provide compression, support, and stabilization to the injured area, assisting in reducing swelling and providing comfort.
Correct Answer is B
Explanation
Choice A Reason:
Administering enemas 2 days before the procedure. Enemas are not typically the primary method of bowel preparation for a colonoscopy. Healthcare providers often recommend specific bowel preparation solutions or laxatives that are more effective in thoroughly cleansing the colon.
Choice B Reason:
This is a standard bowel preparation instruction for colonoscopy to ensure a clear view of the colon during the procedure.
Choice C Reason:
This is not necessary for a colonoscopy. A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.
Choice D Reason:
Expect the provider to schedule another procedure to remove any polyps. While identifying and removing polyps is part of the objective of a colonoscopy, scheduling another procedure specifically for polyp removal isn't usually discussed beforehand. Polyp removal is often performed during the colonoscopy procedure if any are found.
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