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 D
Explanation
A. Ham sandwich with milk. Ham is pork, which is strictly forbidden in kosher diets. Additionally, kosher law prohibits mixing meat and dairy in the same meal, making this option doubly inappropriate.
B. Bacon and cheese quiche with milk. Bacon is derived from pork and is non-kosher. The combination of meat (if using real bacon) and dairy (cheese and milk) also violates kosher dietary restrictions.
C. Shrimp salad and tomato soup with milk. Shellfish like shrimp are not kosher and are strictly avoided. Even though tomato soup and milk may be acceptable, the presence of shrimp makes this tray non-compliant with kosher laws.
D. Scrambled eggs and toast with milk. Eggs are permitted in a kosher diet as long as they do not contain blood spots, and dairy products like milk are also allowed. Since this meal contains no meat or non-kosher items, it aligns with kosher guidelines.
Correct Answer is C
Explanation
A. Provide frequent stimulation for the newborn. Excessive stimulation can worsen symptoms in newborns with neonatal abstinence syndrome (NAS), including irritability, tremors, and difficulty sleeping. These infants need a calm, low-stimulation environment to reduce neurologic stress.
B. Encourage frequent eye contact with the newborn during feedings. While bonding is important, prolonged or forced eye contact can overstimulate a newborn with NAS. These infants often have difficulty regulating sensory input and may become more irritable with excessive interaction.
C. Decrease the lighting levels in the nursery. A dim, quiet environment helps soothe infants experiencing NAS. Reducing lighting can minimize sensory overload, promote rest, and support neurologic regulation during withdrawal.
D. Wrap the newborn loosely in a blanket. Loose wrapping does not provide the security and containment that helps calm an overstimulated infant. Instead, swaddling the newborn snugly can reduce tremors, promote sleep, and offer comfort during withdrawal symptoms.
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