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.

Answer and Explanation

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Finally, the catheter is withdrawn and rotated while suction is applied.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.

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Correct Answer is A

Explanation

The appropriate action for the practical nurse (PN) in this situation would be to ask the client if he is currently hearing voices. This step is important to assess the client's current state and gather information about his experiences. By directly asking the client about hearing voices, the PN can gain insight into the client's symptoms and determine if there is a need for further intervention or support.
B. Having the unlicensed assistive personnel (UAP) escort the client to his room may not be necessary at this point, as the client may simply be engaging in self-talk or may prefer some time alone. However, if the client's behavior becomes disruptive, agitated, or poses a safety risk, involving the UAP or taking other appropriate measures may be warranted.
C. Recording the event is important for documentation purposes, but it should not be the only action taken. It is crucial to actively assess the client's well-being and address any potential concerns or needs.
D. Administering an as-needed (PRN) dose of haloperidol without further assessment or consulting the healthcare provider would be inappropriate. Medication decisions should be based on a comprehensive evaluation of the client's symptoms and the healthcare provider's recommendations.

A. "I realize that life must go on, but sometimes I wonder why." B. "Sometimes I have trouble remembering simple things." C. "I depend on children who fortunately live close-by." D. "I hate that my health does not allow me to do what I used to do." E. "I hate that my health does not allow me to do what I used to do."

Correct Answer is A

Explanation

The statement "I realize that life must go on, but sometimes I wonder why" suggests that the client is experiencing ongoing feelings of sadness, questioning, and possibly struggling to find meaning or purpose in life after the loss of her spouse. This statement indicates a need for bereavement counseling to help the client navigate the grieving process and address the emotional challenges associated with the loss.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with the diagnosis of schizophrenia sitting all alone and talking quietly. Which action should the PN take?

Correct Answer is A

Explanation

Which statement by an older female client who lost her spouse two years ago should indicate to the practical nurse (PN) that the client may need bereavement counseling?

Correct Answer is A

Explanation

The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

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