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 C
Explanation
Choice A Reason:
"I can't change my mind about the care I will receive once I sign my living will." Is incorrect.
This statement suggests a misconception that signing a living will locks in a permanent decision, whereas advance directives can usually be updated or modified as long as the individual is competent to do so.
Choice B Reason:
"If I want life support, I'll need to sign a separate consent form first." Is incorrect. While the concept of a consent form for specific treatments is relevant, it might not fully reflect the broader scope of advance directives, which encompass a range of healthcare preferences beyond just life support.
Choice C Reason:
"I'm glad to have the opportunity to choose what kind of care I receive while I still can." Is correct. This statement reflects the understanding that advance directives offer the opportunity to make decisions about the type of care the client wishes to receive or avoid, empowering them to express their preferences while they are still able to do so.
Choice D Reason:
"Once I fill out my living will, there will be a 1-month delay before it is legally binding." Is incorrect. There isn't typically a standardized waiting period before an advance directive becomes legally binding. The legal validity and activation of advance directives vary by region, but they usually become effective immediately upon completion unless stated otherwise or specific requirements apply.
Correct Answer is ["C","D","E"]
Explanation
Choice A Reason :
Increased peripheral circulation is incorrect. As people age, changes in the cardiovascular system can occur, but increased peripheral circulation isn't a common physiological change. In fact, aging might lead to reduced elasticity in blood vessels, potentially resulting in decreased circulation to some areas.
Choice B Reason:
Increased saliva production is incorrect: Saliva production doesn't usually increase with age. Instead, certain medications, medical conditions, or treatments might impact saliva production. Aging itself doesn't commonly cause an increase in saliva production; in fact, it can decrease due to changes in salivary glands.
Choice C Reason:
Increased constipation is correct. As individuals age, there can be changes in gastrointestinal motility and muscle tone, which can contribute to an increased likelihood of constipation.
Choice D Reason:
Decreased muscle mass is correct. Aging often leads to a natural decline in muscle mass and strength, known as sarcopenia, which can affect mobility and overall physical function.
Choice E Reason:
Decreased cough reflex is correct. With aging, the cough reflex might become less sensitive or effective, which can impact the ability to clear the airways efficiently.
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