56. The practical nurse (PN) is caring for a client who has a tracheostomy tube. After donning sterile gloves, in which sequence should the PN should implement these interventions? (Arrange from the first action on top to last on the bottom.)
Insert sterile suction catheter in tracheostomy tube.
Hyperoxygenate with a bag valve mask (BVM) using a nondominant hand.
Activate suction by covering the catheter opening.
Withdraw and rotate the catheter while suction is applied.
The Correct Answer is B, A, C, D
The correct sequence for the interventions when caring for a client with a tracheostomy tube, after donning sterile gloves, is as follows:
Hyperoxygenate with a bag valve mask (BVM) using a nondominant hand. Insert sterile suction catheter in tracheostomy tube.
Activate suction by covering the catheter opening. Withdraw and rotate the catheter while suction is applied.
The first step is to hyperoxygenate the client using a bag valve mask (BVM) with the nondominant hand. This helps to ensure that the client receives adequate oxygenation during the suctioning procedure.
Next, the sterile suction catheter is inserted into the tracheostomy tube. The catheter is carefully advanced until resistance is met, ensuring it does not force its way in.
After the catheter is inserted, the suction is activated by covering the catheter opening. This creates negative pressure and allows for the removal of secretions.
Finally, the catheter is withdrawn and rotated while suction is applied. This helps to thoroughly suction the secretions from the tracheostomy tube.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When assessing an older client with left-sided heart failure (HF), the most important intervention for the practical nurse (PN) to implement is to auscultate all lung fields. Left-sided heart failure is characterized by the inability of the left ventricle to effectively pump blood, leading to fluid accumulation in the lungs. Auscultating all lung fields allows the PN to assess for the presence of abnormal lung sounds such as crackles, indicating pulmonary congestion.
In summary, when assessing an older client with left-sided heart failure, the most important intervention for the practical nurse (PN) to implement is to auscultate all lung fields. This allows for the detection of abnormal lung sounds associated with pulmonary congestion, a hallmark sign of left-sided heart failure.
Correct Answer is C
Explanation
The action that the practical nurse (PN) should take in this situation is to complete an advance directive form and place it in the client's medical record. Advance directives are legal documents that outline an individual's healthcare preferences and treatment decisions in the event that they become unable to communicate or make decisions for themselves. By completing an advance directive, the client's wishes regarding life-saving measures can be documented and honored.
A. Placing a "Do Not Resuscitate" sign outside the client's door and at the bedside is not sufficient documentation of the client's wishes. While it may serve as a visual reminder to healthcare providers, it is important to have the client's preferences clearly documented in their medical records through a formal advance directive.
B. Reassuring the client that life-saving measures will not be taken without consent is important for establishing trust and communication. However, it is essential to have the client's preferences formally documented to ensure that their wishes are respected and followed.
D. Notifying the client's healthcare provider of the client's wishes is an important step, but it should be done after completing the advance directive form. The advance directive will provide clear instructions to the healthcare team regarding the client's preferences, and the healthcare provider can review and acknowledge these wishes accordingly.
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