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Finally, the catheter is withdrawn and rotated while suction is applied.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 D
Explanation
A thready pulse refers to a pulse that is weak and difficult to palpate. It may disappear or weaken with light pressure. This can be an indication of decreased peripheral perfusion or reduced blood volume. By documenting the finding as "Thready pulse volume," the nurse is accurately describing the quality of the pulse and its response to light pressure.
Incorrect:
A. Missing pulse: A missing pulse would mean that the pulse is not palpable at all, even without applying pressure.
B. Light pressure applied to pulse: This is not a description of the pulse quality, but rather a description of the action taken to assess the pulse.
C. Pulse skips beats: This would mean that the pulse is irregular, with beats being missed or added. In this case, the pulse disappears when light pressure is applied and returns when the pressure is removed, which describes a thready pulse volume.
Correct Answer is ["0.6"]
Explanation
To calculate how many milliliters (mL) the practical nurse (PN) should administer each day, we can first determine the total daily dosage of enoxaparin.
The prescribed dosage is 30 mg every 12 hours, so the total daily dosage is:
30 mg + 30 mg = 60 mg
Next, we can calculate the number of milliliters (mL) needed to deliver the total daily dosage. Since the medication is available in a concentration of 30 mg per 0.3 mL, we can set up a proportion to find the equivalent mL for 60 mg:
30 mg / 0.3 mL = 60 mg / x mL
Cross-multiplying, we get:
30 mg * x mL = 60 mg * 0.3 mL
30x = 18
Dividing both sides by 30, we find:
x = 0.6 mL
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