A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Rationale:

A. Heart rate: Initially elevated (110/min), the client’s heart rate has decreased to 78/min by postpartum day 5, reflecting hemodynamic stability and resolution of infection-related tachycardia.

B. Temperature: Fever present on day 3 (38.6°C) has resolved by day 5 (37.1°C), indicating improved systemic response and reduced inflammation or infection.

C. WBC count: Markedly elevated at 33,000/mm³ on day 3, consistent with postpartum endometritis, has normalized to 10,000/mm³ by day 5, suggesting resolution of infection.

D. Fundal height: Uterine involution is progressing appropriately, moving from 1 cm above the umbilicus to 4 cm below by day 5, indicating the uterus is returning to its non-pregnant state.

E. Lochia: Lochia has changed from moderate, foul-smelling, dark brown on day 3 to a small amount of brownish-red with no odor by day 5, showing improvement in uterine healing and decreased infection.

F. Hemoglobin: The client’s hemoglobin has dropped from 11.1 g/dL to 10 g/dL. While still near the normal postpartum range, this decline does not represent an improvement and may indicate mild ongoing blood loss or dilutional effect.

Rationale:

A. Provide humidification of the room air: Xerostomia, or dry mouth, often results from radiation therapy to the head and neck region. Humidifying room air adds moisture to the environment, helping relieve oral dryness and improving comfort, especially during sleep.

B. Suggest rinsing his mouth with an alcohol-based mouth wash: Alcohol-based mouthwashes can worsen oral dryness and irritate mucosal tissues, making xerostomia more uncomfortable. Clients should instead use alcohol-free or moisturizing rinses.

C. Instruct the client on the use of esophageal speech: Esophageal speech is a communication method taught to clients after laryngectomy, not for xerostomia. It does not address dry mouth and is unrelated to the effects of mandibular radiation.

D. Offer the client saltine crackers between meals: Saltine crackers are dry and salty, which can exacerbate oral dryness and discomfort. Clients with xerostomia benefit more from moist, soft foods and frequent sips of water.