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 C

Explanation

Choice A Reason:

Verifying the bilirubin level of the tube contents is incorrect. Measuring bilirubin levels in the tube contents is not a standard or reliable method for confirming tube placement. It's not an established or recommended technique for this purpose.

Choice B Reason:

Auscultating for air insufflation is incorrect. Auscultation for air insufflation involves injecting air into the tube and listening for bubbling sounds over the stomach area. While this method is commonly used, it can sometimes yield inconsistent or inconclusive results, especially in patients with certain conditions or situations where air movement might not be detectable.

Choice C Reason:

Request a chest x-ray is correct. Obtaining a chest x-ray is the most reliable method to confirm the placement of a feeding tube, especially when the tube is newly inserted or if there are any doubts about its location. A chest x-ray can accurately visualize the position of the tube within the gastrointestinal tract, ensuring it is in the intended location before any feedings or medications are administered.

Choice D Reason:

Checking the pH level of gastric contents is incorrect. Measuring the pH level of aspirated gastric contents can provide information about the acidity of the fluid, indicating gastric placement (pH below 5) in most cases. However, the pH can be influenced by various factors like medications, enteral feeding solutions, or certain medical conditions, making it less reliable than a chest x-ray for definitive confirmation of tube placement.

A. Ask the assist personnel to document the client's time of death. B. Place an identification tag on the outside of the client's shroud. C. Wear sterile gloves when cleaning the client's body. D. Remove the client's dentures and give them to the client's family.

Correct Answer is B

Explanation

A. Asking the assist personnel to document the client's time of death is not correct. While accurate documentation of the time of death is important, the responsibility typically falls on the healthcare provider or physician who confirms the death, not necessarily the assist personnel involved in postmortem care. B. Place an identification tag on the outside of the client's shroud is correct. This action ensures proper identification throughout the postmortem process and aligns with standard procedures for maintaining identification integrity during autopsy procedures. Identifying the client accurately is crucial to prevent any errors or mix-ups. C. Wearing sterile gloves when cleaning the client's body is incorrect. Sterile gloves are not typically required for postmortem care. While gloves are important for infection control, they don't necessarily need to be sterile for handling deceased patients unless there are specific infectious concerns. D. Removing the client's dentures and give them to the client's family is incorrect. In most cases, the client's personal belongings, including dentures, are typically handled according to specific protocols or the family's wishes. However, removing the dentures and giving them to the family isn't typically part of postmortem care. The family might be informed about the presence of dentures and their disposition, but the decision to give them to the family should follow established procedures or the family's preferences.

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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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