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 D
Explanation
Rationale:
A. This response is dismissive and may not address the client's concerns about discussing their decision with loved ones.
B. This response is judgmental and may not support the client's autonomy in making healthcare decisions.
C. This response is dismissive and may not address the client's concerns about discussing their decision with loved ones.
D. This response acknowledges the client's decision and supports the client in discussing their decision with loved ones.
Correct Answer is D
Explanation
Rationale:
A. A fever may influence the result of an oxygen saturation test but is not a direct factor.
B. An elevated hemoglobin level is unlikely to influence the result of an oxygen saturation test.
C. Wearing a ring is unlikely to influence the result of an oxygen saturation test.
D. Wearing nail polish can interfere with the accuracy of pulse oximetry readings by causing an inaccurate reflection of light, leading to a falsely low oxygen saturation reading.
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