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.)

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.

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.

Answer and Explanation

Correct Answer : A,B,C,D,E

1. Unlock and remove the inner cannula (Step C). This is the initial step because it allows access to the inner cannula for cleaning. Removing it enables further cleaning of the inner cannula and ensures proper hygiene of the tracheostomy.

2. Scrub the inside and outside of the inner cannula with a small brush (Step D). Once the inner cannula is removed, it should be cleaned thoroughly to remove any secretions or debris. Scrubbing with a small brush helps in effectively cleaning both the inside and outside surfaces.

3. Wipe the inside of the inner cannula with a folded pipe cleaner (Step E). Using a pipe cleaner helps to reach areas that a brush might not access easily. It further ensures the removal of any remaining secretions or buildup inside the inner cannula.

4. Cleanse the stoma site with 0.9% sodium chloride solution (Step B). After addressing the inner cannula, the nurse moves to clean the stoma site to prevent infection or irritation. This step ensures the area around the tracheostomy is clean and free from contaminants.

5.Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin (Step A). Lastly, preparing the sterile basin with the saline solution should be done at the start to ensure it's ready for use during the cleaning process. This solution will be utilized for cleaning the stoma site in step B and may also be needed for moistening the brush or pipe cleaner during steps D and E.

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Correct Answer is A

Explanation

Choice A Reason:

Measuring the intake and output of a client who has received furosemide is correct. This task involves recording and measuring fluid intake and output, which is typically within the scope of practice for assistive personnel. It requires accurate documentation and doesn't involve making clinical judgments.

Choice B Reason:

Reinforcing teaching with a client about crutch-gait walking is incorrect. Teaching and instructing clients about specific medical procedures or techniques usually require specialized knowledge and assessment skills, typically within the nurse's scope of practice.

Choice C Reason:

Checking a client's peripheral IV site for redness or swelling is incorrect. Assessing for redness or swelling at an IV site involves clinical judgment and assessment skills to identify potential complications. This task is better suited for a licensed nurse who can interpret findings and take appropriate action if needed.

Choice D Reason:

Assessing the pain level of a client who has received acetaminophen is incorrect. Assessing pain levels involves subjective interpretation and understanding of pain scales, which generally falls under the scope of licensed healthcare providers who can evaluate and manage pain interventions based on assessments.

A. Stand on the client's stronger side when moving the client into the chair. B. Pivot on the foot farthest from the bed when assisting the client into the chair. C. Flex hips and knees when assisting the client to a standing position. D. Raise the bed to waist level before moving the client.

Correct Answer is C

Explanation

Correct Answer: C

C. Flex hips and knees when assisting the client to a standing position.Flexing the hips and knees protects the nurse’s back by using proper body mechanics and distributes the force of lifting safely. This position provides stability and reduces the risk of injury to both the nurse and the client during the transfer.

Incorrect answers:

A: "Stand on the client's stronger side when moving the client into the chair."The nurse should stand on the weaker side, not the stronger side, to provide support and assistance where it is most needed. This ensures the client is stabilized and prevents falls or instability due to the weaker side giving way.

B: "Pivot on the foot farthest from the bed when assisting the client into the chair."The nurse should pivot on the foot closest to the chair or the bed to maintain balance and stability. Pivoting on the farthest foot could lead to poor body mechanics and an increased risk of injury to the nurse or client.

D: "Raise the bed to waist level before moving the client." For transferring a client to a chair, the bed should be lowered to a position where the client’s feet can touch the floor. This provides stability and facilitates a safe transfer.

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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.)

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Correct Answer is C

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