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 At this point, it should be slightly withdrawn (1–2 cm) to avoid mucosal damage.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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Related Questions
Correct Answer is D
Explanation
A. Human papillomavirus: Human papillomavirus is widespread and often asymptomatic, but it is not designated as a nationally notifiable disease. Because of its high prevalence and usually non-acute nature, routine reporting to public health authorities is not required.
B. Herpes simplex virus: Herpes simplex virus infections are common and persistent, but they are not included in the list of nationally notifiable diseases. Reporting is not mandatory as outbreaks are typically managed at the individual clinical level without large-scale public health interventions.
C. Candidiasis: Candidiasis is a fungal infection caused by Candida species and is common in many populations. It is not considered a reportable infectious disease because it does not pose a significant public health threat or require epidemiological tracking.
D. Chlamydia: Chlamydia trachomatis infection is one of the most common sexually transmitted infections and is nationally notifiable. Reporting cases to the State health department is mandatory to monitor infection rates, identify outbreaks, and implement prevention and control measures to reduce transmission within the community.
Correct Answer is A
Explanation
A. Reposition the client sideways each hour: Repositioning helps prevent pressure injuries, promotes even distribution of the anesthetic, and reduces the risk of unilateral block or venous stasis, which is especially important after epidural placement.
B. Have protamine sulfate available at the bedside: Protamine sulfate is an antidote for heparin, not epidural anesthesia. It has no role in managing side effects or complications related to an epidural.
C. Monitor the client for hypertension: Epidural anesthesia commonly causes hypotension due to vasodilation. The nurse should monitor for low blood pressure, not elevated readings.
D. Decrease the maintenance infusion rate of IV fluid: IV fluids are often increased prior to and after epidural placement to counteract potential hypotension. Reducing the rate could worsen the risk of low blood pressure.
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