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

Unlock and remove the inner cannula.

Scrub the inside and outside of the inner cannula with a small brush

Wipe the inside of the inner cannula with a folded pipe cleaner.

Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.

Cleanse the stoma site with 0.9% sodium chloride solution.

Answer and Explanation

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

A.   Unlock and remove the inner cannula is the first step because it allows access to the inner cannula for cleaning.
B.   Scrub the inside and outside of the inner cannula with a small brush is the third step because it removes debris and secretions from the inner cannula.
C.   Wipe the inside of the inner cannula with a folded pipe cleaner is the fourth step because it further cleans the inner cannula.
D.   Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin is the second step because it provides the solution for cleaning the inner cannula.

E.   Cleanse the stoma site with 0.9% sodium chloride solution is the final step because it cleans the stoma site before replacing the inner cannula.

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Correct Answer is A

Explanation

Rationale:

A. A photograph is a unique identifier that helps ensure the correct client receives the correct medications.

B. A medical diagnosis is not a unique identifier and may not be accurate if the client has multiple diagnoses.

C. A room number is not a unique identifier and may not be accurate if the client has been moved to a different room.

D. Age is not a unique identifier and may not be accurate if the client has multiple ages.

A. A pair of sterile forceps is allowed to rest in a container of sterile water on the field. B. The sterile solution is poured with the bottle held over the field. C. Unnecessary sterile items are placed on the field. D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.

Correct Answer is B

Explanation

Rationale:

A. Allowing sterile forceps to rest in a container of sterile does not affect the sterility of the field.

B. Pouring sterile solution with the bottle held over the field is an inappropriate technique since it breaches the sterility of the field.

C. Placing unnecessary sterile items on the field is not ideal, but it does not indicate contamination of the surgical field.

D. The handle of a pair of sterile scissors resting 5 cm (2 in) from the field's edge does not indicate contamination of the surgical field. The scissors should be placed within easy reach of the nurse but should not touch non-sterile items.

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A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete 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

Correct Answer is A

Explanation

Correct Answer is B

Explanation

Nurses' Notes

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Resources

A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete 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 preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?

Correct Answer is A

Explanation

A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has a BMI of 29. The nurse should document that the client is in which of the following weight categories?

A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?

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A nurse is reviewing the medical record of a client who has a paralytic ileus. Exhibits Select words from the choices below to fill in each blank in the following sentence: The findings in the client's medical record indicate dropdownand dropdown.

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A nurse is caring for a client who has a new colostomy. The client refuses to participate in her ostomy care, saying, "I'm not touching that thing." Which of the following actions should the nurse take?

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Nurses' Notes