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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?
- A. Unlock and remove the inner cannula.
- B. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
- C. Scrub the inside and outside of the inner cannula with a small brush.
- D. Wipe the inside of the inner cannula with a folded pipe cleaner.
- E. Cleanse the stoma site with 0.9% sodium chloride solution.
Correct Answer: B,A,C,D,E
Rationale: B: Prepare solution. A: Remove cannula. C: Scrub cannula. D: Wipe cannula. E: Cleanse stoma maintains sterility.
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A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?
- A. Review the client's photograph in the medical record.
- B. Request an assistive personnel to identify the client.
- C. Ask the client to state their room number.
- D. Have the client state their phone number.
Correct Answer: A
Rationale: A photograph ensures accurate identification, critical for a client with dementia unable to self-identify.
A nurse is assisting in the care of a client who is postoperative following a hip arthroplasty in the orthopedic unit. The primary health care provider has prescribed pain management and positioning strategies to prevent complications. Complete the following sentence by using the lists of options. The client is at risk for developing ___ due to ___.
- A. Constipation
- B. Opioid use
- C. indigestion
- D. water consumption
Correct Answer: A,B
Rationale: A: Opioids slow bowel motility. B: Common side effect of pain management.
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Using a quick-release tie to secure the restraint.
- B. Tying the restraint to the bed frame.
- C. Placing the restraint across the client's chest.
- D. Applying the restraint over the client's gown.
Correct Answer: C
Rationale: Placing the restraint across the chest restricts breathing and is unsafe, requiring intervention.
A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?
- A. Isopropyl alcohol.
- B. Hydrogen peroxide.
- C. Chlorhexidine gluconate.
- D. Chlorine bleach.
Correct Answer: D
Rationale: Chlorine bleach effectively kills bloodborne pathogens like HIV and hepatitis B.
A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?
- A. Stand with the crutch tips against the feet.
- B. Bear weight on the unaffected leg.
- C. Keep the crutches at the level of the axillae.
- D. Hold the arms straight when walking.
Correct Answer: B
Rationale: Weight on the unaffected leg is key to the three-point gait for stability.