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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While a respiratory therapist may be involved in the care of a client with dysphagia, their primary focus is on respiratory function rather than swallowing difficulties.
B. A speech-language pathologist specializes in the assessment and treatment of swallowing disorders (dysphagia) and would be the most appropriate interprofessional team member to address this client's needs.
C. A registered dietitian may be involved in the client's care to provide guidance on appropriate nutrition and dietary modifications, but they do not typically specialize in the assessment and
treatment of dysphagia.
D. An occupational therapist may be involved in the client's care for other aspects of
rehabilitation, such as activities of daily living and upper extremity function, but they do not typically specialize in the assessment and treatment of dysphagia.
Correct Answer is D
Explanation
A. Clients with expressive aphasia have difficulty expressing themselves verbally but can often understand spoken language. It's important for the nurse to provide the teaching without
expecting a verbal response from the client. The client may still benefit from receiving information even if they cannot verbally respond.
B. Speaking loudly is not helpful for clients with expressive aphasia and may increase confusion or frustration. The nurse should speak clearly and at a normal volume.
C. Facial gestures can aid in communication for clients with expressive aphasia by providing additional cues. The nurse should use facial expressions to enhance communication.
D.Clients with expressive aphasia have difficulty expressing themselves verbally. Assessing the client's ability to use alternative communication methods, such as a communication board, can help facilitate effective communication and understanding of the teaching.
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