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.)

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.

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.

Answer and Explanation

Correct Answer : A,B,C,D,E

1. Unlock and remove the inner cannula (Step C). This is the initial step because it allows access to the inner cannula for cleaning. Removing it enables further cleaning of the inner cannula and ensures proper hygiene of the tracheostomy.

2. Scrub the inside and outside of the inner cannula with a small brush (Step D). Once the inner cannula is removed, it should be cleaned thoroughly to remove any secretions or debris. Scrubbing with a small brush helps in effectively cleaning both the inside and outside surfaces.

3. Wipe the inside of the inner cannula with a folded pipe cleaner (Step E). Using a pipe cleaner helps to reach areas that a brush might not access easily. It further ensures the removal of any remaining secretions or buildup inside the inner cannula.

4. Cleanse the stoma site with 0.9% sodium chloride solution (Step B). After addressing the inner cannula, the nurse moves to clean the stoma site to prevent infection or irritation. This step ensures the area around the tracheostomy is clean and free from contaminants.

5.Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin (Step A). Lastly, preparing the sterile basin with the saline solution should be done at the start to ensure it's ready for use during the cleaning process. This solution will be utilized for cleaning the stoma site in step B and may also be needed for moistening the brush or pipe cleaner during steps D and E.

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Correct Answer is B

Explanation

Choice A Reason:

Applying intermittent suction for up to 30 seconds is incorrect. While suctioning is necessary for tracheostomy care, the duration and frequency of suctioning should be based on the client's need and should typically last no more than 10-15 seconds to prevent hypoxemia and tissue damage.

Choice B Reason:

Preoxygenate the client prior to suctioning is correct. Preoxygenation helps ensure that the client has adequate oxygen levels before the suctioning procedure, reducing the risk of hypoxemia or decreased oxygen levels during and after suctioning

Choice C Reason:

Instruct the client to swallow during catheter insertion is incorrect. Instructing the client to swallow during catheter insertion is not a standard procedure for tracheostomy care. Swallowing doesn't have a direct association with the suctioning process.

Choice D Reason:

Apply suction while inserting the catheter is incorrect. Applying suction during catheter insertion can cause tissue damage and should be avoided. Suction should only be applied when withdrawing the catheter to remove secretions from the tracheostomy tube.

A. "He appears anxious about the transfer." B. "He is allergic to sulfa." C. "His partner has been visiting." D. "He is voiding adequately."

Correct Answer is B

Explanation

Choice A Reason:

"He appears anxious about the transfer."While this might be relevant in certain contexts, it is subjective and less critical compared to other clinical information. The transfer report should prioritize objective data that directly impacts the client’s care.

Choice B Reason:

"He is allergic to sulfa." Allergies are crucial information that must be communicated during any transfer. This ensures that the receiving healthcare team is aware and can avoid administering medications that could cause an allergic reaction. This is important information to include in the transfer report.

Choice C Reason:

"His partner has been visiting." While it may be helpful to know about the client’s support system, this information is not as critical as details about the client's health status, medications, or allergies.

Choice D Reason:

"He is voiding adequately." Voiding patterns can be relevant, particularly if there have been recent issues with urinary function or if the client is being monitored for urinary output. However, unless there is a specific reason this is critical to ongoing care, it may not be the most essential information to include.

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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

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Explanation

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Correct Answer is B

Explanation

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