A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Unlock and remove the inner cannula.

Scrub the inside and outside of the inner cannula with a small brush

Wipe the inside of the inner cannula with a folded pipe cleaner.

Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.

Cleanse the stoma site with 0.9% sodium chloride solution.

Answer and Explanation

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

A.   Unlock and remove the inner cannula is the first step because it allows access to the inner cannula for cleaning.
B.   Scrub the inside and outside of the inner cannula with a small brush is the third step because it removes debris and secretions from the inner cannula.
C.   Wipe the inside of the inner cannula with a folded pipe cleaner is the fourth step because it further cleans the inner cannula.
D.   Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin is the second step because it provides the solution for cleaning the inner cannula.

E.   Cleanse the stoma site with 0.9% sodium chloride solution is the final step because it cleans the stoma site before replacing the inner cannula.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

A. Despite the client reporting thirst and frequent urination, the client's urine specific gravity of 1.010 is within the normal range (1.005 to 1.030). The above symptoms could be associated with the hyperglycemia.

B. There is no indication of a pneumothorax in the nurse's notes or diagnostic results.

C. The casual glucose level of 300 mg/dL is significantly above the normal range (less than 200 mg/dL), indicating hyperglycemia.

D. The client’s WBC level is elevated, 11,500/mm3 (5,000 to 10,000/mm3) thus indicating an infection.

A. To an insurance agency in regard to a life insurance policy B. To a family member when the client is not available C. To a medical interpreter service on behalf of a client D. To an employer for a pre-employment screening

Correct Answer is C

Explanation

Rationale:

A. Disclosing health information to an insurance agency without written consent is a violation of client confidentiality.

B. Disclosing health information to a family member without written consent is a violation of client confidentiality.

C. Disclosing health information to a medical interpreter service on behalf of a client is permissible under HIPAA regulations, as long as the interpreter is bound by confidentiality requirements.

D. Disclosing health information to an employer without written consent is a violation of client confidentiality.

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A nurse is preparing to provide tracheostomy care to a client who has a chronic tracheostomy. In which order should the nurse complete 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 reviewing the medical record of a client who has a paralytic ileus. Exhibits Select words from the choices below to fill in each blank in the following sentence: The findings in the client's medical record indicate dropdownand dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?

Correct Answer is C

Explanation

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