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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Documenting the status of the episiotomy, including its size and approximation, is important for monitoring wound healing and ensuring appropriate postpartum care.
B. While providing self-care instructions is important, it is not a specific documentation related to the postpartum condition.
C. Fluid intake with meals is important for overall health but may not be specifically related to the postpartum condition.
D. Documenting an elevated oral temperature may be relevant for assessing the client's health status but is not specific to the postpartum condition.
Correct Answer is C
Explanation
Rationale:
A. This response dismisses the concerns of the assistant personnel and is not supportive.
B. This response minimizes the assistant personnel's concerns and does not acknowledge their feelings.
C. This response acknowledges the assistant personnel's concerns and opens the door for further discussion.
D. This response does not address the assistant personnel's concerns and suggests a formal complaint as the only solution. It is not supportive or collaborative.
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