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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 placing them in the order of performance. Use all the steps.)
- A. Wipe the inside of the inner cannula with a folded pipe cleaner.
- B. Unlock and remove the inner cannula.
- C. Scrub the inside and outside of the inner cannula with a small brush
- D. Cleanse the stoma site with 0.9% sodium chloride solution.
- E. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
Correct Answer: E,B,C,A,D
Rationale: E: Prepare solution. B: Remove cannula. C: Scrub cannula. A: Wipe cannula. D: Cleanse stoma ensures sterile technique.
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A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Use a 10-mL syringe filled with cleansing solution.
- B. Cleanse the wound with cotton balls.
- C. Dry the wound bed with gauze squares.
- D. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
Correct Answer: D
Rationale: Holding the syringe 2.5 cm above provides adequate pressure for irrigation without trauma.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Determine the client's ability to use a communication board.
- C. Speak with a loud voice while providing the information.
- D. Avoid the use of facial gestures during the instructions.
Correct Answer: B
Rationale: A communication board aids clients with expressive aphasia in responding, enhancing understanding.
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Add 0.5 mL of diluent to the medication.
- B. Use a filter needle to aspirate the medication.
- C. Inject air into the ampule prior to drawing the medication into a syringe.
- D. Cleanse the tip of the ampule with an alcohol swab after opening.
Correct Answer: B
Rationale: A filter needle prevents glass particles from being drawn into the syringe from the ampule.
A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?
- A. Oral temperature elevated at 0800.
- B. Episiotomy approximated, 3 cm (1.18 in) in length.
- C. Client instructed on self-care needs.
- D. Client drank adequate amounts of fluid with meals.
Correct Answer: B
Rationale: Specific documentation like episiotomy status provides measurable, objective data.
A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?
- A. Keep their arms at the sides of their body with their hands in a relaxed position.
- B. Interlock their fingers and hold their hands away from their body above their waist.
- C. Clasp their hands together in a relaxed position behind their body at their waist.
- D. Place one hand over the other against the part of the gown covering their upper body.
Correct Answer: B
Rationale: Interlocking fingers above the waist keeps hands sterile and away from contamination.