A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

Applies suction during catheter removal

Suctions for 30 seconds

Preoxygenates with 100% oxygen

Auscultates breath sounds

Answer and Explanation

The Correct Answer is A

A. Applies suction during catheter removal: This is correct. Suction should only be applied when the catheter is being inserted into the tracheostomy, not when it is being removed. Applying suction during removal can cause trauma to the airway and disrupt the patient's airway integrity.

B. Suctions for 30 seconds: Suctioning for 30 seconds is generally within the recommended limit for suctioning. Prolonged suctioning can lead to hypoxia and other complications, but 30 seconds is a safe duration for most patients.

C. Preoxygenates with 100% oxygen: This is correct practice. Preoxygenating the patient before suctioning is important to avoid hypoxia, especially in patients with respiratory concerns.

D. Auscultates breath sounds: This is good practice. Auscultating breath sounds before and after suctioning helps assess the patient's respiratory status and can guide the nurse in evaluating the need for suctioning.

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Correct Answer is D

Explanation

A. "Soak in a bathtub of hot water." – Soaking in hot water is not recommended during pregnancy, as it can cause overheating and affect blood flow, potentially leading to complications such as fainting or preterm labor.

B. "Obtain a prescription for pramipexole." – Pramipexole is a medication primarily used for Parkinson’s disease and restless legs syndrome, and it is not typically prescribed to address sleep disturbances during pregnancy.

C. "Use a transcutaneous electrical nerve stimulator (TENS)." – TENS is not generally recommended for treating sleep disturbances during pregnancy. It is more commonly used for pain management.

D. "Lie on your left side with your top leg forward." – Lying on the left side with the top leg forward is a recommended sleeping position during pregnancy, as it can improve blood circulation to the fetus and reduce pressure on the vena cava, which can help improve sleep and comfort

A. Assist the client into a supine position. B. Explain that nonreactivity might require immediate medication administration. C. Remind the client to press the button when she feels fetal movement. D. Tell the client the test should take about 10 min.

Correct Answer is C

Explanation

A. Assist the client into a supine position is incorrect. A supine position can reduce uterine blood flow and may lead to hypotension. The nurse should assist the client into a left-lateral position for optimal results during a nonstress test.

B. Explain that nonreactivity might require immediate medication administration is incorrect. Nonreactivity can indicate fetal distress, but it does not necessarily require medication immediately. Further testing or evaluation would be needed first.

C. Remind the client to press the button when she feels fetal movement is correct. The purpose of the nonstress test is to monitor fetal heart rate acceleration in response to movement. The client is typically instructed to press a button when she feels fetal movement so the nurse can correlate it with fetal heart rate patterns.

D. Tell the client the test should take about 10 min is incorrect. The nonstress test typically takes 20–40 minutes, depending on fetal activity and the need for monitoring.

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A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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