Nokea
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. Scrub the inside and outside of the inner cannula with a small brush
- C. Wipe the inside of the inner cannula with a folded pipe cleaner.
- D. Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin.
- E. Cleanse the stoma site with 0.9% sodium chloride solution.
Correct Answer: A, D, B, C, E
Rationale: Sequence ensures sterile preparation and cleaning: remove cannula, prepare solution, scrub, wipe, cleanse stoma.
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A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clean around the stoma with a moisturizing soap.
- B. I will press on the skin barrier for 30 seconds to ensure that it adheres.
- C. I will cut an opening in the skin barrier that is 1/2 inch larger than the stoma.
- D. I will apply a thin layer of talc powder around the stoma before placing the appliance.
Correct Answer: B
Rationale: Pressing the barrier ensures a secure seal, preventing leaks.
A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?
- A. Apply lidocaine gel to the urethra.
- B. Inflate the catheter's balloon.
- C. Lower the penis to a 45° angle.
- D. Twist the catheter gently.
Correct Answer: C
Rationale: Lowering the penis aligns the urethra, reducing resistance.
A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?
- A. The client has a fever.
- B. The client has an elevated hemoglobin level.
- C. The client is wearing a ring.
- D. The client is wearing nail polish.
Correct Answer: D
Rationale: Nail polish can interfere with pulse oximetry readings by absorbing light.
A nurse is collecting data from a client who has an acute condition. Which of the following findings should the nurse identify as increasing the risk for potential client injuries?
- A. Hearing acuity intact
- B. Oriented to person only
- C. Full range of motion bilateral lower extremities
- D. Ability to use call light
Correct Answer: B
Rationale: Orientation to person only indicates confusion, increasing injury risk.
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. Placing the restraint across the client's chest
- B. Applying the restraint over the client's gown
- C. Using a quick-release tie to secure the restraint
- D. Tying the restraint to the bed frame
Correct Answer: A
Rationale: Placing the restraint across the chest restricts breathing; it should be at the waist.