13. 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.

Unlock and remove the inner cannula.

Scrub the inside and outside of the inner cannula with a small brush.

Cleanse the stoma site with 0.9% sodium chloride solution.

Wipe the inside of the inner cannula with a folded pipe cleaner.

Answer and Explanation

The Correct Answer is A,B,C,E,D

Correct Order of Steps: A. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin. This step ensures the nurse has a sterile solution ready for cleaning the cannula and stoma site. B. Unlock and remove the inner cannula. Removing the inner cannula is necessary to clean it and prevent the buildup of secretions. C. Scrub the inside and outside of the inner cannula with a small brush. Cleaning the cannula thoroughly removes debris and secretions. E. Wipe the inside of the inner cannula with a folded pipe cleaner. The pipe cleaner is used to dry and clear any residual moisture or secretions inside the cannula. D. Cleanse the stoma site with 0.9% sodium chloride solution. Cleansing the stoma site is essential to maintain skin integrity and prevent infection.

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Correct Answer is A

Explanation

A) Unequal height of the shoulders - This finding is characteristic of scoliosis, as the curvature of the spine may cause one shoulder to appear higher than the other.
B) Expansion of the upper intercostal spaces - Expansion of the intercostal spaces is not a typical finding in scoliosis and may indicate other respiratory or musculoskeletal conditions.
C) Increased convex curve of the cervical spine - While scoliosis can affect the entire spine, an increased convex curve in the cervical spine is not typically associated with scoliosis.
D) Increased concave curve of the thoracic spine - While scoliosis often involves a lateral curvature of the spine, an increased concave curve of the thoracic spine alone may not be indicative of scoliosis.

A. Use a narrower cuff to repeat the BP measurement. B. Request a prescription for an antihypertensive medication. C. Deflate the cuff faster when repeating the BP measurement. D. Measure the client's BP in the other arm.

Correct Answer is D

Explanation

A) Use a narrower cuff to repeat the BP measurement. - Using a narrower cuff is not appropriate and may result in inaccurate BP readings.
B) Request a prescription for an antihypertensive medication. - This action is premature based on a single elevated BP reading and should be guided by the provider's assessment and recommendations.
C) Deflate the cuff faster when repeating the BP measurement. - The speed of cuff deflation does not significantly affect BP measurement accuracy, and this action may not address the underlying cause of the elevated BP.
D) Measure the client's BP in the other arm. - Confirming the elevated BP with a reading from the other arm can help determine if the elevation is due to positioning or equipment error.

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13. 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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?

Correct Answer is A

Explanation

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SpO2 level is 88% while on room air. Which of the following actions should the nurse take first?

A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which of the following volumes should the nurse record on the I&O?

13. 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.)

A nurse is collecting data from a client who has diabetes mellitus. The nurse should ask which of the following questions to determine the client's ability to provide foot self- hygiene?

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days, which of the following laboratory findings should the nurse expect?

A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?