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 A

Explanation

A. Gloves should be removed first to prevent contamination of the hands when removing other protective equipment.
B. The gown can be removed after gloves to prevent contamination of clothing underneath.

C. Goggles should be removed after gloves and gown to prevent contamination of the face.

D. The mask should be removed last to provide continued protection against airborne contaminants.

A. Secure the restraints with a square knot. B. Check the client's range of motion every 6 hr. C. Make sure two fingers fit under the restraints. D. Request a prescription renewal from the provider every 36 hr.

Correct Answer is C

Explanation

A. Securing the restraints with a square knot may be too tight and could restrict circulation or cause injury. Using a quick-release knot is preferable to allow for quick removal if necessary.
B. While it is important to assess the client's range of motion regularly, this action does not directly address the proper application of the restraints.

C. This is the correct action to ensure that the restraints are not too tight, allowing for adequate circulation and preventing injury. The ability to fit two fingers under the restraints ensures that they are applied with proper tension.
D. Requesting a prescription renewal from the provider every 36 hours may be necessary according to facility policy, but it does not directly address the proper application of the
restraints.

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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.)

Nursing Test Bank

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Correct Answer is A

Explanation

A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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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.)