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. Nail polish can interfere with the accuracy of pulse oximetry readings by absorbing or

reflecting light, leading to falsely low oxygen saturation readings. It's essential to remove nail polish or acrylic nails from the finger used for pulse oximetry to obtain accurate results.
B. While an elevated hemoglobin level may affect the oxygen-carrying capacity of the blood, it does not directly influence the accuracy of pulse oximetry readings.

C. Fever may affect oxygen saturation levels indirectly by increasing metabolic demand or
respiratory rate, but it does not directly interfere with the accuracy of pulse oximetry readings.
D. Wearing a ring does not typically interfere with pulse oximetry readings unless the ring is very tight and impairs blood flow to the finger. However, nail polish is a more significant
concern for accurate readings.

A. Unnecessary sterile items are placed on the field. B. The sterile solution is poured with the bottle held over the field. C. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge. D. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.

Correct Answer is B

Explanation

A. Placing unnecessary sterile items on the field is not ideal, but it does not indicate contamination of the surgical field.

B. Pouring sterile solution with the bottle held over the field is an inappropriate technique since it breaches the sterility of the field.

C. The handle of a pair of sterile scissors resting 5 cm (2 in) from the field's edge does not indicate contamination of the surgical field. The scissors should be placed within easy reach of the nurse but should not touch non-sterile items.

D. Allowing sterile forceps to rest in a container of sterile does not affect the sterility of the field.

View Question and Answer

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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 requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?

Correct Answer is B

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.)