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)

Answer and Explanation

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 At this point, it should be slightly withdrawn (1–2 cm) to avoid mucosal damage.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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Bowel movement 5 days ago: Constipation is a common side effect of morphine and should be addressed, but it is not immediately life-threatening and can be managed with laxatives or stool softeners.
B. Pupil diameter 6 mm: Pupil dilation is not a typical concern with morphine; miosis (constriction) is more commonly expected. While abnormal pupil size can indicate neurologic or drug-related issues, hypotension takes priority here.
C. Blood pressure 80/40 mm Hg: Hypotension is a serious adverse effect of morphine that may indicate circulatory depression. It requires immediate intervention to prevent inadequate organ perfusion and potential shock.
D. Urinary output 120 mL/4 hr: This output equals 30 mL/hr, which is within the expected minimum range. No immediate intervention is required, though continued monitoring is appropriate.

A. Metabolic acidosis B. Hyperactive bowel sounds C. Distended abdomen D. Passing flatus

Correct Answer is C

Explanation

A. Metabolic acidosis: Small bowel obstructions are more commonly associated with metabolic alkalosis due to loss of gastric contents from vomiting. Acidosis is less typical in the early stages of obstruction.
B. Hyperactive bowel sounds: In nonmechanical (paralytic ileus) obstruction, bowel sounds are usually absent or hypoactive, not hyperactive, due to lack of peristalsis. Hyperactive sounds are more typical in early mechanical obstruction.
C. Distended abdomen: Abdominal distention is a classic sign of bowel obstruction, resulting from gas and fluid accumulation above the site of obstruction. It is expected in both mechanical and nonmechanical types.
D. Passing flatus: The absence of flatus is common in bowel obstruction, as bowel movement is halted. Continued passage of flatus would suggest partial or resolving obstruction, not a typical finding in active nonmechanical obstruction.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving morphine IV for pain. Which of the following findings should the nurse report to the provider first?

Correct Answer is C

Explanation

A burse is assessing a client who is 3 days postoperative and has a nonmechanical obstruction of the small bowel. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse in an urgent care clinic is caring for an infant who presents with vomiting. diarrhea. and decreased oral intake. Which of the following manifestations should the nurse expect?

A nurse is caring for a client who is obese. The client is crying and states. "Everyone is staring at me because of my weight." Which of the following responses should the nurse make?

A nurse is caring for a client who has a fractured leg and rates their pain as 7 on a scale of O to 10. Which of the following medications should the nurse expect to administer?

A nurse receives a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the parent?

A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?

A nurse is caring for the client. Exhibits Select the 5 findings that indicate the client's condition has improved.

A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?