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 B
Explanation
Rationale:
A. Using the incentive spirometer is important for preventing atelectasis, but it does not prevent orthostatic hypotension.
B. Dangling the legs over the side of the bed before standing helps reduce the risk of orthostatic hypotension by allowing the body to gradually adjust to the change in position.
C. Increasing protein intake is important for wound healing and tissue repair, but it does not prevent orthostatic hypotension.
D. Performing regular isometric exercises is important for maintaining muscle strength and mobility, but it does not prevent orthostatic hypotension.
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.
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