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 D
Explanation
Rationale:
A. Telling the nurse that permission from the risk manager is required to view the client's record is not accurate and may not address the situation appropriately.
B. Contacting facility security to remove the nurse from the unit is not necessary and may not address the situation appropriately.
C. Completing an incident report about the breach of confidentiality may be appropriate later if the situation escalates or if there is no resolution after speaking to the nurse. However, the immediate step is to address the breach directly.
D. Reminding the nurse that only staff caring for the client may access the client's record is the correct action. The nurse should remind the colleague that access to a client's medical record is restricted to those directly involved in their care. This respects patient confidentiality and complies with legal and ethical guidelines.
Correct Answer is C
Explanation
Rationale:
A. Cleansing the client's outer ear with isopropyl alcohol to remove wax is not recommended because it can cause irritation and dryness.
B. Pulling the client's pinna downward and back is an incorrect technique for instilling otic medication in an adult client. An adult ear should be pulled upwards and backwards.
C. Holding the ear dropper 1 cm (0.5 in) from the client's ear is accurate.
D. Requesting the client remain supine for 10 min following administration is not necessary and may not be practical, instead the client should lie on the contralateral side.
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