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Finally, the catheter is withdrawn and rotated while suction is applied.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 A
Explanation
A. Checking the medical record for the correct signed consent form prior to the examination is the primary responsibility of the practical nurse (PN). Ensuring that the consent form is properly signed and documented in the medical record is crucial for legal and ethical reasons before proceeding with any invasive procedure.
B. While explaining the examination is important, obtaining informed consent is the responsibility of the provider, not the PN. The PN can clarify information but should not be the one to explain the procedure in detail and obtain the signature.
C. Explaining the procedure to a family member and obtaining their signature is not appropriate, as consent must come from the client unless they are incapacitated. Family members cannot give consent for procedures unless legally designated as such.
D. While asking if the client understands the exam and the need for the consent form is a good practice for ensuring informed consent, the PN's responsibility focuses more on verifying that the consent has been properly obtained and documented.
Correct Answer is A
Explanation
Repositioning the client helps alleviate any discomfort or pressure points that may be interfering with their ability to find a comfortable sleeping position. Providing a back rub can promote relaxation and help the client feel more comfortable.
It is important to address non-pharmacological interventions first before considering medication options. In this case, repositioning and providing a back rub are non-invasive, non-pharmacological interventions that can be effective in promoting sleep.
B. Offering a cup of hot chocolate at bedtime may not address the underlying cause of the client's difficulty in sleeping and may not be the most appropriate intervention at this time.
C. Similarly, administering a prescribed sleep medication should only be considered after non-pharmacological interventions have been attempted and if deemed necessary by the healthcare provider.
D. Administering an as-needed (PRN) prescription for pain may be appropriate if pain is contributing to the client's difficulty in sleeping. However, repositioning and providing a back rub can be the initial interventions to address discomfort and pain before considering additional pain medication.
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