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. Place the tip of the thermometer under the center of the infant's axilla: This is the correct method for taking an axillary temperature in infants, which is the recommended route due to safety and ease. The tip should be placed snugly in the center of the axilla and the infant's arm should be held firmly against their body to ensure accuracy.
B. Pull the pinna of the infant's ear forward before inserting the probe: This technique is used for otoscopic or tympanic temperature readings in children under 3, but tympanic readings are not preferred in young infants due to the small size and curvature of their ear canals, which can lead to inaccuracy.
C. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is inappropriate for infants. They may not be able to keep the thermometer properly positioned, which increases the risk of inaccurate readings or injury.
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal temperature measurement is not routinely recommended unless specifically indicated, and the probe should only be inserted about 1.3 cm (0.5 in) for infants to avoid rectal perforation. The option listed suggests unsafe depth.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
Explanation
- Deep vein syndrome: This is not a recognized condition. The intended term may have been deep vein thrombosis (DVT), which is a valid orthopedic complication, but the clinical findings in this scenario point more urgently toward compartment syndrome and infection.
- Osteomyelitis: The client has an open fracture with drainage from the splint, a significantly elevated WBC count (28,000/mm³), and a high fever (38.9°C / 102°F). These findings suggest the development of a bone infection (osteomyelitis), especially in the context of recent surgery and internal fixation.
- Fat embolism syndrome: While fat embolism is a risk with long bone fractures, this client is not displaying key hallmark signs such as respiratory distress, petechiae, or altered mental status. The findings are more consistent with infection and circulatory compromise.
- Compartment syndrome: The client has classic signs including cool foot, numbness, inability to move toes, absent pulses, delayed capillary refill, and increased pain. These are hallmark signs of neurovascular compromise from compartment syndrome, a surgical emergency.
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