11. A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box, placing them in the selected order of performance. Use all the steps.)
Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in).
Insert the catheter until resistance is felt.
Lubricate the catheter with sterile saline.
Rotate the catheter while suctioning.
The Correct Answer is C,B,A,D
C. Lubricate the catheter with sterile saline. After donning sterile gloves, the nurse should lubricate the catheter to reduce friction and prevent trauma to the tracheal mucosa during insertion.
B. Insert the catheter until resistance is felt. The catheter should be gently inserted into the tracheostomy until resistance is met, indicating that it has reached the carina. Inserting beyond this point may cause injury.
A. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in). Pulling back slightly after resistance ensures the catheter is not pressing directly on sensitive structures and is positioned correctly for effective suctioning.
D. Rotate the catheter while suctioning. Suction should be applied while withdrawing the catheter in a rotating motion to evenly clear secretions and minimize damage to the tracheal lining.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Shows perfectionism. Clients with obsessive-compulsive personality disorder (OCPD) are characterized by perfectionism, a preoccupation with orderliness, control, and rules, and a need for mental and interpersonal control, often at the expense of flexibility and efficiency.
B. Takes advantage of others. This behavior is more typical of antisocial personality disorder, not OCPD. Clients with OCPD tend to be highly conscientious, not manipulative or exploitative.
C. Irritability. While clients with OCPD may become frustrated or anxious if things are not done their way, chronic irritability is not a hallmark feature of the disorder.
D. Impulsivity. Impulsivity is more commonly associated with borderline or antisocial personality disorders. In contrast, clients with OCPD are typically rigid, cautious, and rule-bound.
Correct Answer is D
Explanation
A. Match the client's blood type with the type and cross match specimen. While type and crossmatch are important for allogeneic transfusions, an autologous transfusion uses the client’s own previously donated blood, so this is not the primary method for identification.
B. Confirm the provider's prescription matches the number on the blood component. Although important, this step alone does not verify the client’s identity. The nurse must also confirm the blood unit matches the correct client.
C. Ask the client to state his blood type and the date of the blood donation. Client recall is not a reliable form of identification for transfusion safety, as it is prone to error or misunderstanding.
D. Ensure that the client's identification band matches the number on the blood unit. This is the correct and safest method to confirm identity before administering an autologous blood product. It ensures the blood product is matched to the correct patient.
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