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A nurse is preparing to perform tracheostomy care for a client.
In which order should the nurse take the following steps?

(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Apply clean tracheostomy ties.

Wear clean gloves to remove the tracheostomy dressing.

Ensure a method to communicate during the procedure.

Clean the inner cannula using a small brush.

Answer and Explanation

The Correct Answer is C,B,D,A

The correct order is:

1. Ensure a method to communicate during the procedure.

2. Wear clean gloves to remove the tracheostomy dressing.

3. Clean the inner cannula using a small brush.

4. Apply clean tracheostomy ties.

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Correct Answer is A

Explanation

Choice A rationale

Infiltration occurs when IV fluid leaks into the surrounding tissue, causing edema, coolness, and tenderness at the insertion site. This can lead to discomfort and complications if not promptly addressed.

Choice B rationale

Nerve damage from IV therapy usually presents as pain, numbness, or tingling rather than edema and coolness. It results from inadvertent injury to a nerve during catheter insertion or from prolonged pressure on a nerve.

Choice C rationale

Phlebitis is inflammation of the vein, characterized by redness, warmth, and tenderness along the vein. It does not typically cause coolness or extensive edema.

Choice D rationale

Infection at the catheter insertion site usually presents with redness, warmth, and purulent discharge, rather than coolness and edema. Tenderness can be present, but other signs of infection would also be observed.

A. Absence of dizziness. B. Decreased incisional pain. C. Decreased dysrhythmias. D. Absence of nausea.

Correct Answer is D

Explanation

Choice A rationale

Aprepitant is an antiemetic used to prevent nausea and vomiting, particularly in chemotherapy patients. Absence of dizziness is not a primary therapeutic effect of this medication.

Choice B rationale

Decreased incisional pain is not related to the function of aprepitant. Pain management involves different classes of medications, such as analgesics or opioids.

Choice C rationale

Decreased dysrhythmias are not associated with aprepitant's mechanism of action. Cardiac rhythm management requires specific medications targeting heart rhythm disorders.

Choice D rationale

Absence of nausea is a primary therapeutic effect of aprepitant, which works by blocking neurokinin-1 receptors involved in inducing nausea and vomiting. It is effective in managing nausea in patients undergoing chemotherapy. .

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A nurse is preparing to perform tracheostomy care for a client. In which order should the nurse take 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 D

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A nurse is preparing to perform tracheostomy care for a client.
In which order should the nurse take the following steps?

(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)