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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Telling the client that it is safe to touch her ostomy may not address the client's concerns or fears.
B. Requesting that someone from the client's family participate in the care may not address the client's concerns or fears.
C. Asking the client to explain her feelings allows the nurse to understand the client's concerns or fears and address them appropriately.
D. Explaining why her participation is important may not address the client's concerns or fears.
Correct Answer is B
Explanation
Rationale:
A. Drinking an average of 2,000 milliliters of water daily is a healthy habit that promotes bowel elimination.
B. Taking a prescribed opioid pain medication at bedtime can cause constipation and impaired bowel elimination.
C. Eating apples and black-eyed peas is a healthy dietary choice that promotes bowel elimination.
D. Drinking two hot cups of coffee each morning can promote bowel elimination for some individuals.
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