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 B
Explanation
Rationale:
A. Clamping the tube when going for a walk is not recommended because it can cause urine to back up into the bladder.
B. Keeping the drainage bag below the level of the waist is recommended to prevent reflux of urine and reduce the risk of infection.
C. Emptying the drainage bag once a day may not be frequent enough to prevent urinary stasis and infection.
D. Applying antiseptic ointment to the tip of the penis is not recommended because it can cause irritation and discomfort.
Correct Answer is B
Explanation
Rationale:
A. A client who has rubella may be at risk for acquiring varicella from the client with herpes zoster.
B. A client who has had varicella is immune to varicella and is not at risk for acquiring herpes zoster from the client.
C. A client who is HIV-positive may be at risk for acquiring varicella from the client with herpes zoster.
D. A client who has tuberculosis may be at risk for acquiring varicella from the client with herpes zoster.
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