128. 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 on the right. placing them in the selected order of performance, use all the steps.) (ORDERED RESPONSE)
Insert the catheter until resistance is felt
Lubricate the catheter with sterile saline
Rotate the catheter while suctioning
Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in)
The Correct Answer is B,A,D,C
After donning sterile gloves, the nurse must first lubricate the catheter with sterile saline to reduce friction during insertion. The catheter is then inserted gently until resistance is felt, indicating it has reached the tracheal wall. At this point, it should be slightly withdrawn (1–2 cm) to avoid mucosal damage. Suction is then applied while rotating the catheter to evenly clear secretions from the airway.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. “I wear a hat and long sleeves while I am working.”: This suggests protective behavior that reduces the risk of sun exposure, heat-related illnesses, and contact with harmful agricultural chemicals, indicating awareness of occupational safety.
B. “I am currently sharing my home with two roommates.”: Although crowded living conditions can increase transmission risk of communicable diseases, this alone is not immediately indicative of a health hazard without other factors like poor sanitation.
C. “I eat vegetables directly from the field where I work.”: Consuming unwashed produce in the field exposes individuals to pesticide residues, soil contaminants, and pathogens, posing a significant health risk that requires immediate education and intervention.
D. “My home has running water and electricity.”: Access to clean water and electricity supports good hygiene and safe food preparation, which are positive indicators of living conditions that help reduce health risks.
Correct Answer is B
Explanation
A. Remind the client to eat scheduled meals daily: At the end of life, appetite often decreases, and forcing scheduled meals can cause discomfort. Encouraging small, preferred foods as tolerated is more appropriate.
B. Offer the client a blanket to keep warm: Clients nearing end of life often experience cold intolerance due to decreased circulation and metabolism. Providing warmth helps maintain comfort and dignity.
C. Speak in a loud tone when addressing the client: Speaking loudly can be perceived as disrespectful or frightening, especially if the client is confused or hearing impaired. A calm, gentle tone is more supportive.
D. Place the client in a supine position: The supine position may increase discomfort or breathing difficulties in some terminal clients; positioning should focus on comfort and ease of breathing, often semi-Fowler’s or side-lying
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