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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 C

Explanation

Choice A rationale

Having clear liquids up to 3 hours before the procedure is incorrect. Clients are generally advised to be NPO (nothing by mouth) for a certain period before a bronchoscopy to prevent aspiration.

Choice B rationale

Eating as soon as the procedure is completed is incorrect. Clients need to wait until their gag reflex has returned before eating or drinking to prevent choking or aspiration.

Choice C rationale

Blood-tinged sputum after the procedure is an expected finding. Bronchoscopy can cause minor irritation and bleeding in the airways, leading to blood-tinged sputum.

Choice D rationale

Receiving an injection of radioactive material prior to the procedure is incorrect. This statement confuses bronchoscopy with other diagnostic tests such as a PET scan. Bronchoscopy involves direct visualization of the airways using a bronchoscope. .

A. The client's capillary refill is 3 seconds. B. The client's fingers are cool to the touch. C. The client reports severe itching under the cast. D. The client reports increased pain at the area of the fracture.

Correct Answer is D

Explanation

Choice A rationale

A capillary refill time of 3 seconds is slightly prolonged but not as concerning as other symptoms. Monitoring is warranted, but it is not an immediate priority.

Choice B rationale

Cool fingers can indicate reduced circulation, but it requires further assessment to determine its significance. Immediate attention is needed if accompanied by other severe symptoms.

Choice C rationale

Severe itching can be uncomfortable and may indicate skin irritation, but it is not typically a medical emergency.

Choice D rationale

Increased pain at the fracture site can indicate complications such as compartment syndrome, which requires immediate medical intervention to prevent permanent damage.

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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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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.)