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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
The stoma bleeds lightly when touched is incorrect. Some minor bleeding during the initial postoperative period is expected due to surgical trauma. Light bleeding when touched might not be unusual in the immediate days following colostomy placement.
Choice B Reason:
The stoma appears dark in color is correct. A dark-colored stoma could indicate compromised blood supply or ischemia, which is a concerning finding postoperatively. It's crucial to report this change in color promptly to the provider for further evaluation and intervention.
Choice CReason:
The stoma is draining a small amount of liquid stool is incorrect. In the early postoperative period, drainage of liquid stool from the stoma is normal. The digestive system needs time to adapt to the new anatomy created by the colostomy, and initially, the stool consistency might be liquid before it starts to normalize.
Choice DReason:
The stoma protrudes slightly from the abdomen is incorrect. A slightly protruding stoma is a common and expected finding after colostomy surgery. It's often a normal part of the healing process as the stoma settles and adjusts.
Correct Answer is D
Explanation
Choice A Reason:
"We can discuss this when you're not feeling overwhelmed." Is incorrect. This response acknowledges the partner's feelings but doesn't directly address their concern about missing social outings. It offers to revisit the topic later, which might be helpful, but it doesn't provide immediate support or suggestions.
Choice B Reason:
"I understand how you feel. I've had a relative go through the same thing." Is incorrect. While expressing empathy is essential, comparing experiences might inadvertently minimize the partner's feelings. Each situation is unique, and the partner might need specific advice or support tailored to their circumstances.
Choice C Reason:
"Have you tried taking your partner with you when you go out?" is incorrect. This response suggests a potential solution by proposing involving the client with Alzheimer's in social outings. However, in advanced stages, this might not always be feasible or suitable due to the nature of the condition. It's essential to be sensitive to the client's needs and abilities.
Choice D Reason:
"Tell me more about your expectations." Is correct. This response invites the partner to share more about their feelings and desires without assuming a solution. It opens a dialogue to understand the partner's concerns and expectations better, allowing the nurse to offer appropriate support or guidance.
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