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 A
Explanation
Choice A Reason:
A client who has ulcerative colitis is correct. Ulcerative colitis, a type of inflammatory bowel disease (IBD), involves chronic inflammation and ulceration in the colon and rectum. This condition often results in bleeding from the inflamed mucosa, leading to the presence of blood in the stool that can be detected by a fecal occult blood test.
Choice B Reason:
A client who has stomatitis is incorrect. Stomatitis refers to inflammation in the mouth and does not typically cause bleeding in the gastrointestinal tract, which is what the fecal occult blood test detects. Stomatitis involves oral lesions or sores but does not directly impact stool blood content.
Choice C Reason:
A client who uses laxatives is incorrect. Laxative use does not necessarily cause bleeding in the gastrointestinal tract. While some laxatives can potentially irritate the intestinal lining, leading to minor bleeding in some cases, the presence of blood in the stool due to laxative use is less common compared to conditions like ulcerative colitis, where chronic inflammation and ulceration lead to significant bleeding.
Choice D Reason:
A client who has cholecystitis is incorrect. Cholecystitis is inflammation of the gallbladder and does not directly involve bleeding in the gastrointestinal tract. It typically presents with symptoms related to gallbladder inflammation such as abdominal pain, nausea, and vomiting, rather than causing bleeding that would be detected by a fecal occult blood test.
Correct Answer is D
Explanation
Choice A Reason:
Turn on loud music in client care areas is incorrect. This action might increase stress rather than reduce it. Loud noises or music can be distressing for clients, especially in a healthcare setting where rest and recovery are crucial. It's generally better to maintain a calm and quiet environment.
Choice B Reason:
Assign different nurses to provide care for clients each day is incorrect. Continuity of care is often beneficial for clients, as it fosters trust and familiarity. Having different nurses daily might disrupt this continuity and potentially increase stress for clients who prefer consistent caregivers.
Choice C Reason:
While offering some choices can empower clients and reduce stress, too many choices might overwhelm them, particularly in an acute care setting. The key is to provide a balance of autonomy while not overwhelming the client.
Choice D Reason:
Limiting the number of visitors can help create a quieter, more controlled environment, reducing overstimulation and stress for clients. This can be particularly important in an acute care setting where rest and a calm environment are crucial for recovery.
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