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 C

Explanation

Choice A Reason:

Nerve damage is incorrect. Nerve damage typically presents with symptoms such as altered sensation, numbness, tingling, or shooting pain along the path of the nerve. The symptoms described in the scenario are more indicative of localized inflammation rather than nerve-related issues.

Choice B Reason:

Infection is incorrect. Infection at the insertion site can manifest with redness, warmth, tenderness, and possibly purulent drainage. While infection is a potential complication of IV therapy, the symptoms described might indicate a different issue.

Choice C Reason:

Infiltration is correct. Infiltration occurs when the IV fluid leaks into the surrounding tissues. Symptoms often include swelling, coolness, and tenderness at the site due to the fluid accumulating in the tissue instead of going into the vein. These symptoms align with the description provided.

Choice D Reason:

Phlebitis is incorrect. Phlebitis is the inflammation of a vein, typically presenting with redness, warmth, and tenderness along the vein's path.

A. The client has a delayed response to verbal commands. B. The client has ecchymosis around the eyes. C. The client is unable to remember details of the motor-vehicle crash. D. The client reports ringing in the ears.

Correct Answer is A

Explanation

Choice A Reason:

The client has a delayed response to verbal commands. This finding can indicate increased intracranial pressure. Changes in responsiveness, such as delayed responses to verbal commands or other stimuli, can be indicative of neurological impairment due to elevated pressure within the skull.

Choice B Reason:

The client has ecchymosis around the eyes. Ecchymosis around the eyes (raccoon eyes) can occur with certain head injuries, but it's not a direct sign of increased intracranial pressure. It's more commonly associated with basilar skull fractures rather than specifically reflecting increased pressure within the skull.

Choice C Reason:

The client is unable to remember details of the motor-vehicle crash. Memory impairment or amnesia regarding the event can occur due to head trauma, but it might not directly correlate with an increase in intracranial pressure. It's more related to the effects of the injury on memory function.

Choice D Reason:

The client reports ringing in the ears. Tinnitus or ringing in the ears might occur in some cases of head trauma but is not a direct indicator of increased intracranial pressure. It might result from the impact of the injury or other associated factors.

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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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