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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A Reason:

Ensure the blinds in the client's room remain open is not appropriate. Bright light can contribute to sensory overload. It's better to create a subdued and calming environment, so keeping the blinds closed or partially closed might help reduce excess stimuli.

Choice B Reason:

Place the client in a room near the nurses' station is not appropriate. Being near the nurses' station could increase the noise and activity around the client, potentially worsening sensory overload. It's advisable to place the client in a quieter area away from high-traffic zones to minimize auditory and visual stimulation.

Choice C Reason:

Play quiet music in the client's room is incorrect. While soothing music might help some individuals relax, for someone experiencing sensory overload, even low-volume music could add to the stimuli. Silence or minimal ambient noise might be more beneficial.

Choice D Reason:

Break up nursing care into small, frequent sessions is correct. This action is beneficial for managing sensory overload. Breaking up care into smaller sessions allows for adequate rest periods between activities, reducing the overall sensory input at any given time.

A. Isopropyl alcohol B. Bleach C. Hydrogen peroxide D. Chlorhexidine

Correct Answer is B

Explanation

Choice A Reason:
Isopropyl alcohol is the appropriate cleaning agent. While alcohol can be used as a disinfectant for some purposes, it might not be as effective as bleach against bloodborne pathogens like HIV. Bleach is generally recommended for disinfection in this context.
Choice B Reason:
Bleach is recommendable. Bleach is effective in disinfecting surfaces contaminated with bloodborne pathogens, including HIV. It's recommended for cleaning and disinfecting areas contaminated with blood as it can effectively kill many pathogens, including viruses like HIV. The standard recommendation is to create a solution of bleach and water to clean surfaces contaminated with blood.
Choice C Reason:
Hydrogen peroxide is not recommendable. Hydrogen peroxide has some disinfectant properties, but bleach is more effective against bloodborne pathogens like HIV when used to clean contaminated surfaces.
Choice D Reason:
Chlorhexidine is not appropriate. Chlorhexidine is an antiseptic commonly used for skin disinfection before procedures. While it's effective for certain purposes, it's not typically recommended for disinfecting surfaces contaminated with bloodborne pathogens like HIV. Bleach is the preferred agent in such cases.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 caring for a client who has cardiomyopathy and is experiencing sensory overload. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a newly licensed nurse who is caring for a client who has AIDS. The nurse should instruct the newly licensed nurse to clean spills of the client's blood with a solution of water and which of the following cleaning agents?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about environmental modifications in the home with a family member of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching?

A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

A nurse is reinforcing discharge teaching for a client who had a cerebrovascular accident (CVA) and requires assistance to perform their ADLs. Which of the following statements should the nurse provide?

A nurse is reinforcing teaching with a client who has a prescription for sublingual nitroglycerin for unstable angina. Which of the following instructions should the nurse include in the instructions?

A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?

A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client asks the nurse why she needs to take four different antituberculotic medications. Which of the following replies should the nurse make?

A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?