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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Hyperkalemia is incorrect. Vomiting and diarrhea typically lead to a loss of potassium rather than an increase. These conditions often result in depletion of electrolytes, including potassium, due to the loss of fluids.
Choice B Reason:
Hypocalcemia is correct. While prolonged or severe diarrhea could potentially lead to some electrolyte imbalances, hypocalcemia is not typically a primary finding associated with vomiting and diarrhea. Calcium levels may not be significantly affected by these symptoms compared to sodium and potassium.
Choice C Reason:
Hypermagnesemia is incorrect. Similar to calcium, magnesium levels are not usually significantly impacted by vomiting and diarrhea alone. Hypermagnesemia is more commonly associated with excessive intake of magnesium-containing medications or renal dysfunction rather than acute gastrointestinal symptoms.
In a client experiencing vomiting and diarrhea, the loss of fluids and electrolytes due to these symptoms commonly leads to:
Choice D Reason:
Hyponatremia is correct. Vomiting and diarrhea can cause a loss of sodium and water, leading to decreased sodium levels in the blood, which manifests as hyponatremia. This electrolyte imbalance is a typical finding in individuals experiencing gastrointestinal issues with fluid loss.
Correct Answer is C
Explanation
Choice A Reason:
While documenting the refusal is important for accurate record-keeping and to ensure communication among the healthcare team, addressing the client's immediate concerns and attempting to resolve the issue of medication refusal should take precedence before documenting.
Choice B Reason:
Returning the medication is a procedural step but is not the immediate action needed when a client refuses medication due to adverse effects. First, it's important to address the client's concerns and discuss the potential consequences of refusal.
When a client refuses medication due to experiencing adverse effects, the initial action for the nurse to take is:
Choice C Reason:
Inform the client of the potential consequences of their refusal is correct. It's essential to engage in a conversation with the client to understand their concerns and educate them about the potential consequences of not taking their antihypertensive medication. The nurse should discuss the risks associated with untreated high blood pressure to ensure the client is informed about the importance of the prescribed medication.
Choice D Reason:
Notifying the provider is important, but it is generally done after the nurse has attempted to address the client’s concerns and informed them of the consequences. The provider should be informed if the refusal persists or if the nurse believes the situation requires further medical intervention.
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