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 A

Explanation

Choice A Reason:

Assisting the client to the restroom 30 minutes after meals is correct recommendation. This intervention aligns with the natural response of the gastrocolic reflex, which often leads to increased colonic motility after eating. Timing the restroom visit to this period can take advantage of the body's natural tendency to have a bowel movement after meals, potentially aiding in achieving bowel continence.

Choice B Reason:

Limiting the client's physical activity until bowel continence is achieved is not appropriate. Physical activity can actually stimulate bowel function and regularity. Moderate physical activity, as appropriate for the client's condition, can promote regular bowel movements. Restricting physical activity might hinder the overall success of bowel training.

Choice C Reason:

Limiting the client's fluid intake to 1500 mL/dayis not appropriate. Adequate hydration is crucial for bowel health and regularity. Limiting fluid intake could lead to dehydration and constipation, which can exacerbate fecal incontinence. It's important to encourage adequate hydration unless there are specific medical reasons to restrict fluids.

Choice D Reason:

Instructing the client to limit their intake of high-fiber foods is incorrect. High-fiber foods are beneficial for bowel regularity and can help manage fecal incontinence by promoting healthy bowel movements. Limiting high-fiber foods could potentially lead to constipation or exacerbate the issue of fecal incontinence.

A. Inform the client of the adverse effect of diarrhea. B. Monitor the client for weight loss. C. Advise the client about increased dry mouth. D. Check the client for increased hypopigmentation under the patch.

Correct Answer is C

Explanation

Choice A Reason:
Informing the client of the adverse effect of diarrhea is less common with clonidine use, especially in comparison to other side effects like dry mouth or skin irritation.
Choice B Reason:
Monitoring for weight loss isn't a primary concern specifically associated with transdermal clonidine use.
Choice C Reason:
Advise the client about increased dry mouth. Dry mouth is a common adverse effect of clonidine, including the transdermal form. Patients should be informed about this so they can manage it effectively, for example, by drinking plenty of water or using sugar-free gum or candy to stimulate saliva production.
Choice D Reason:
Hypopigmentation is not a commonly reported issue with transdermal clonidine patches. However, local skin irritation or rash can occur at the site of the patch.

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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

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?

Correct Answer is A

Explanation

A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?

Correct Answer is C

Explanation

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