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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Obtain verbal consent from the client. - While obtaining verbal consent is important, for invasive procedures like catheter insertion, it's essential to have written, witnessed consent to ensure proper documentation and confirmation that the client is fully informed and agrees to the procedure.
B) Witness the client's signature on a consent form. - Express consent for medical procedures typically involves the client signing a consent form after being adequately informed about the procedure, its potential risks, benefits, and alternatives. Witnessing the client's signature on a consent form ensures that the client has provided informed consent for the specific procedure.
C) Check the medical record for the client's signature on a previous consent form. - Consent for procedures should ideally be obtained for each specific instance, especially for invasive procedures.
D) Have another nurse co-sign the client's consent. - Co-signing consent is not necessary for minor procedures like urinary catheter insertion; verbal consent from the client is sufficient.
Correct Answer is A
Explanation
A. Discontinue supplements containing vitamin C 24 hr before the test- Vitamin C can interfere with fecal occult blood testing, leading to false-positive results. Instructing the client to discontinue such supplements helps ensure accuracy.
B. Refrain from consuming pork 7 days before the test- There is no evidence to suggest that consuming pork affects fecal occult blood testing.
C. Place a thick layer of stool on the specimen card- A thin smear of stool is typically used for fecal occult blood testing.
D. Urinate prior to collecting the stool specimen- Urination does not impact fecal occult blood testing.
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