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 ["10"]
Explanation
Given:
Diphenhydramine syrup: 12.5 mg/5 MLX
Required dose: 25 mg
First, determine the ratio of the available dosage strength to the required dose:
12.5 mg (available dose) / 5 mL (volume) = 25 mg (required dose) / X mL
Cross-multiply to find X (the amount of syrup needed):
12.5 mg X mL = 25 mg 5 mL
Now, solve for X:
X = (25 mg 5 mL) / 12.5 mg
X = 125 / 12.5
X = 10
Therefore, the nurse should administer 10 mL of diphenhydramine syrup to provide a dose of 25 mg to the older adult client with rhinitis.
Correct Answer is B
Explanation
Choice A Reason:
Leaving the television on is incorrect. Constant background noise from the television might be overwhelming and confusing for someone with Alzheimer's. It's generally better to have a quiet and calming environment to reduce agitation and confusion.
Choice B Reason:
Installing locks at the top of doors is correct. This can be an essential safety measure to prevent the person from wandering or accessing unsafe areas. Installing locks higher up on doors can help prevent the individual from opening doors and wandering into potentially dangerous situations.
Choice C Reason:
Placing throw rugs on the floor is incorrect. Throw rugs pose a tripping hazard, especially for individuals with Alzheimer's who might have mobility issues or difficulties with depth perception. Removing throw rugs or securing them firmly to the floor is essential to prevent falls.
Choice D Reason:
Scheduling alternate caregivers is incorrect. While having alternate caregivers is important for support, it doesn't directly relate to environmental modifications within the home.
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