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) Recheck the client's SaO2 level after having the client cough and clear their throat.

- This action helps determine if the low SaO2 level is due to a transient cause such as mucus or secretions blocking the airway.
B) Notify the charge nurse of the client's condition. - While important, this action should come after assessing and addressing the client's immediate needs.
C) Review the client's most recent SaO2 level in the medical record. - This information may provide context but does not address the current low SaO2 level.
D) Check the client's medical records to see which medications were recently admitted. - Medications may contribute to respiratory issues, but addressing the client's immediate respiratory distress takes priority.

A. Determine if the client has a support system. B. Schedule a mental health consult for the client. C. Provide the client with information about coping strategies. D. Encourage the client to attend a support group.

Correct Answer is A

Explanation

A) Determine if the client has a support system. - Assessing the client's current support network is essential to determine available resources and potential interventions.
B) Schedule a mental health consult for the client. - While mental health support may be necessary, understanding the client's existing support system is the first step.
C) Provide the client with information about coping strategies. - Providing coping strategies is important but should come after assessing the client's support system.

D) Encourage the client to attend a support group. - Encouraging attendance at support groups can be helpful, but it's important to assess the client's current support system first.

View Question and Answer

Body System	Findings
Neurological	Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	: Lungs clear
Cardiovascular	: Heart rate irregular, Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

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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 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?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

Exhibits The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

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