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. Chvostek's sign is a clinical sign observed during physical examination that may indicate hypocalcemia. It is elicited by tapping or lightly striking the facial nerve just anterior to
the earlobe, which can cause twitching of the facial muscles, particularly the muscles around the mouth and nose.
B. This image shows winging of the scapula. Winging of the scapula, also known as
scapular winging, is a condition characterized by the abnormal protrusion or prominence of the scapula away from the back wall of the thorax. Normally, the scapula lies flat
against the rib cage, providing stability and support for arm movements.

A. Use of cutting board B. Amount of time washing hands C. Time leftovers sit unrefrigerated on countertop D. Refrigerator temperature E. Defrosting of frozen foods F. Leftover storage time in refrigerator

Correct Answer is ["A","B","E","F"]

Explanation

A. The use of separate cutting boards for raw meats and vegetables is a fundamental food safety practice to prevent cross-contamination. On Day 14, the client demonstrates an
understanding of this by using one cutting board for raw meats and a different one for vegetables.
B. Increasing the handwashing time from 10 seconds to 15 seconds is in line with food safety guidelines, which recommend washing hands for at least 20 seconds to effectively remove germs.
C. Additionally, there was no information provided on the time leftovers sat unrefrigerated on the countertop, which should be minimized to prevent bacterial growth.
D. The client did not demonstrate an understanding of safe refrigerator temperatures as the temperature did not meet the recommended setting of 4° C (40° F) or below.
E. Defrosting frozen foods in the refrigerator is a safe practice to prevent the growth of harmful bacteria, which can occur when foods are defrosted on the countertop.
F. Discarding leftovers after 2 days minimizes the risk of foodborne illnesses, as the longer food is stored, even in the refrigerator, the higher the risk of bacterial growth.

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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

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has hypomagnesemia. Which of the following findings should the nurse identify as a positive Chvostek's sign? Image A Image B

Correct Answer is A

Explanation

Correct Answer is ["A","B","E","F"]

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.)