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Finally, the catheter is withdrawn and rotated while suction is applied.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

Explanation

The activity that the PN should suggest to meet the physical and social needs of wheelchair-bound older residents who are mentally alert is an outdoor game of balloon
volleyball. It promotes physical activity, coordination, and social interaction among the residents. It allows them to engage with each other, participate in a fun and inclusive game, and enjoy the outdoor environment. Balloon volleyball can be adapted to accommodate individuals with varying abilities and provide an enjoyable and stimulating experience for wheelchair-bound residents who are mentally alert.
A. A picnic in the park: While a picnic in the park can be enjoyable, it may pose challenges for wheelchair-bound individuals in terms of accessibility and maneuverability. It might limit their participation and engagement in the activity.
B. An outdoor concert: While an outdoor concert can be entertaining, it may not actively engage wheelchair-bound residents. They may be limited in their ability to fully participate and interact with others during the concert.
D. A tea party in the courtyard: While a tea party can be a pleasant social activity, it may not provide the desired physical engagement for wheelchair-bound residents. They may require activities that involve more movement and physical participation.

A. Use a cushion when sitting. B. Weigh every morning. C. Perform a range of motion exercises. D. Document abdominal girth. E. None F. None

Correct Answer is B

Explanation

A. Using a cushion when sitting may provide comfort, but it does not directly address the client's elevated blood pressure or changes in mental status related to chronic kidney disease (CKD).
B. Weighing every morning is crucial in managing CKD, particularly with elevated blood pressure, as it helps monitor fluid retention, which can indicate worsening kidney function or fluid overload. This intervention is essential for assessing the client's condition and adjusting treatment as needed.
C. Performing range of motion exercises is important for maintaining mobility, especially in an immobile client; however, it does not directly address the pressing issues of elevated blood pressure and altered mental status.
D. Documenting abdominal girth can be important for assessing fluid retention, but it is less immediate than daily weight monitoring for a client with CKD showing significant symptoms.

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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

The practical nurse (PN) is assisting the recreational director of a long-term care facility in planning outdoor activities for wheelchair-bound older residents who are mentally alert. Which activity should the PN suggest that meets the physical and social needs of these residents?

Correct Answer is C

Explanation

A client is being treated for chronic kidney disease (CKD). On examination, the client has elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

Correct Answer is B

Explanation

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