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.)

Ensure a method to communicate during the procedure.

Wear clean gloves to remove the tracheostomy dressing.

Clean the inner cannula using a small brush.

Explain the procedure to the client.

Apply clean tracheostomy ties.

Answer and Explanation

The Correct Answer is D, A, B, C, E

D. Explain the procedure to the client. Before starting any procedure, explaining it to the client helps reduce anxiety and ensures cooperation. A. Ensure a method to communicate during the procedure. Since the client may have difficulty speaking, establishing a method of communication (such as hand signals or a writing board) is essential to ensure their comfort and safety during the procedure. B. Wear clean gloves to remove the tracheostomy dressing. Putting on clean gloves is important before touching the site and removing the dressing to prevent infection. C. Clean the inner cannula using a small brush. Cleaning the inner cannula is critical to prevent the buildup of secretions and ensure the airway remains clear. E. Apply clean tracheostomy ties. Once the site is cleaned and the cannula is secured, applying new, clean ties will ensure the tracheostomy tube remains in place and secure.

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Correct Answer is B

Explanation

Choice A Reason:
"Will use ibuprofen when I have a headache." This statement is inappropriate. Enoxaparin is an anticoagulant, and using nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can increase the risk of bleeding. So, using ibuprofen isn't recommended without consulting a healthcare professional while on enoxaparin.
Choice B Reason:
“Will use an electric razor for shaving.” This statement is correct. Enoxaparin is an anticoagulant, and using a sharp razor increases the risk of bleeding. Using an electric razor reduces the chance of nicks or cuts that could lead to bleeding complications while on this medication.
Choice C Reason:
“Will avoid the use of stool softeners." This statement is inappropriate. Enoxaparin doesn't directly interact with stool softeners. However, it's crucial to consult a healthcare provider before taking any new medications, including stool softeners, while on enoxaparin, as there might be potential interactions or effects on clotting.
Choice D Reason:
"I will massage the site after each injection." This statement is inappropriate. Massaging the site after an enoxaparin injection could potentially cause bruising or irritation. The usual recommendation is to apply gentle pressure at the injection site for a short time after the injection but not to massage it vigorously.

A. Replace the unit when the drainage chamber is full. B. Clamp the tube for 30 min every 8 hr. C. Pin the tubing to the client's bed sheets. D. Monitor for at least 150 mL of drainage every hour.

Correct Answer is A

Explanation

Choice A Reason:
Replace the unit when the drainage chamber is full is correct. Regularly emptying the drainage chamber when it becomes full is essential to ensure the drainage system functions properly and continues to effectively remove fluids or air from the chest cavity.

Choice B Reason:
Clamp the tube for 30 min every 8 hr. is incorrect.
Clamping a chest tube without a specific medical order or indication can lead to complications such as a buildup of pressure within the chest cavity or potential damage to the lungs. It's generally not a routine action to clamp the tube without proper instruction.

Choice C Reason:
Pin the tubing to the client's bed sheets is incorrect. Pinning the tubing to the bed sheets can cause tension on the chest tube, leading to accidental dislodgment or obstruction. The tubing should be secured but not pinned to prevent inadvertent movement.

Choice D Reason:
Monitor for at least 150 mL of drainage every hour is incorrect. There isn't a standard or prescribed amount of drainage that should occur hourly. The nurse should monitor the drainage rate and characteristics but shouldn't expect a specific volume within a set timeframe. Monitoring for excessive or decreased drainage and changes in characteristics is crucial, but an hourly volume expectation isn't appropriate.

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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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Explanation

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Explanation

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