48. 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.

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

Cleanse the stoma site with 0.9% sodium chloride solution.

Answer and Explanation

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

Pouring 0.9% sodium chloride solution into the sterile basin provides the solution necessary for cleaning the inner cannula.

Unlocking and removing the inner cannula is the first step in the process of tracheostomy care.

Scrubbing the inside and outside of the inner cannula with a small brush helps remove secretions and debris.

Wiping the inside of the inner cannula with a folded pipe cleaner further cleans the inner surfaces.

Cleansing the stoma site with 0.9% sodium chloride solution completes the tracheostomy care procedure.

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Correct Answer is D

Explanation

A. This response may be perceived as judgmental and could potentially worsen the client's anxiety or stress.
B. While involving the doctor may eventually be necessary, it's important for the nurse to first acknowledge and respect the client's decision.
C. Asking "why" may seem confrontational and might not foster a therapeutic relationship. It's important to respect the client's autonomy and decision-making process.
D. This response acknowledges the client's decision and demonstrates understanding and acceptance, which can help build trust and rapport between the nurse and the client.

A. Keep legs straight. B. Bend at the waist. C. Hold object away from the body. D. Tighten the abdominal muscles.

Correct Answer is D

Explanation

A. Keep legs straight: Keeping the legs straight while lifting can strain the back muscles and increase the risk of injury. Instead, the legs should be bent at the knees to provide better support.
B. Bend at the waist: Bending at the waist can also strain the back muscles and increase the risk of injury. The correct technique is to bend at the knees and hips while keeping the back straight.
C. Hold object away from the body: Holding objects close to the body while lifting can help reduce strain on the back. Holding objects away from the body can increase the risk of injury.
D. Tighten the abdominal muscles: Tightening the abdominal muscles can help stabilize the core and support the back during lifting, reducing the risk of injury.

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48. 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.)

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48. 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.)