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 ["B","C","E"]

Explanation

A) A client reports being dissatisfied with the temperature of the meals provided. - This situation does not pose a risk to the client's safety or result in harm, so an incident report is not necessary.

B) A client receives burns from a heating pad. - Any incident resulting in harm to the client, such as burns from a heating pad, should be documented with an incident report.
C) A client becomes disoriented and falls out of bed. - Falls resulting in injury or disorientation require documentation via an incident report.
D) A client is unable to afford the physical therapy that the provider recommends. - Financial constraints do not necessitate an incident report.
E) A client's visitor becomes dizzy and faints in the client's room. - Incidents involving visitors, especially if they occur in the client's presence, should be documented with an incident report.

A. Administer a sedative medication to the client. B. Have the client sign an against medical advice form. C. Tell the client that the surgeon will prescribe restraints if they try to leave. D. Explain to the client that they cannot leave until the surgeon discharges them.

Correct Answer is D

Explanation

A. Administer a sedative medication to the client- Administering a sedative medication without proper indication and consent is not appropriate in this situation.
B. Have the client sign an against medical advice form- Having the client sign an against medical advice (AMA) form is premature and should only be considered after thorough discussion of the risks and benefits of leaving against medical advice.
C. Tell the client that the surgeon will prescribe restraints if they try to leave- Threatening the client with restraints is coercive and not conducive to a therapeutic nurse-client relationship. Restraints should only be used as a last resort to ensure safety.
D. Explain to the client that they cannot leave until the surgeon discharges them- The nurse should explain to the client that leaving before being discharged by the surgeon can jeopardize their recovery and may result in complications. It is important to communicate the consequences of leaving prematurely and encourage the client to wait for proper discharge instructions.

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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 caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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