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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. The nurse cannot adjust IV antibiotic schedules solely for convenience, as consistent timing is necessary to maintain therapeutic drug levels.
B. Infusing vancomycin at a faster rate is unsafe and increases the risk of complications such as red man syndrome.
C. This is incorrect because the 2-hour administration window applies to non–time-critical medications. IV antibiotics like vancomycin are time-critical and must be given within 30 minutes of the scheduled time.
D. Time-critical medications, such as IV antibiotics, must be administered within 30 minutes before or after the scheduled time, making this the most accurate response.

A. Choose a vein that is palpable and straight. B. Select a site on the client's dominant arm C. Elevate the client's arm prior to insertion D. Apply a tourniquet below the venipuncture site

Correct Answer is A

Explanation

A. Choose a vein that is palpable and straight. A palpable, straight vein provides the best access for successful IV catheter insertion. It allows for easier threading of the catheter and reduces the risk of complications like infiltration.
B. Select a site on the client's dominant arm. The non-dominant arm is usually preferred to minimize interference with daily activities and reduce the risk of dislodgement due to frequent use.
C. Elevate the client's arm prior to insertion. Elevating the arm can decrease venous filling, making veins less prominent and harder to access. Instead, the arm should be placed in a dependent position to promote vein distention.
D. Apply a tourniquet below the venipuncture site. The tourniquet should always be placed above the insertion site to restrict venous return and make the veins more prominent and easier to access.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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