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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I can take antacids at the same time as this medication.": This is incorrect. Pantoprazole is a proton pump inhibitor (PPI), and taking antacids at the same time can interfere with the medication's effectiveness. It is generally recommended to space out antacids and PPIs by at least 1 hour.
B. "I have to take this medication on an empty stomach.": This is correct. Pantoprazole should be taken on an empty stomach, typically 30 minutes before breakfast, to optimize absorption and effectiveness.
C. "I should expect to have diarrhea while taking this medication.": Diarrhea is not a common side effect of pantoprazole. While side effects such as headache, nausea, and abdominal pain are more common, diarrhea is not typically expected.
D. "I will need to remain upright for 1 hour after taking the medication.": This is incorrect. While it is generally advised to remain upright for a period after taking medications like bisphosphonates, it is not required for pantoprazole. The main instruction for pantoprazole is to take it on an empty stomach before eating.
Correct Answer is C
Explanation
A. Wearing a mask by family members is not typically necessary at home once the client is on effective treatment for tuberculosis and the infectious period has passed. The client should avoid public places and limit contact with vulnerable individuals, but family members do not need to wear masks at home after the initial treatment phase.
B. Long-term medication is required for tuberculosis, but not for the rest of the client’s life. Treatment usually lasts for 6-9 months, not a lifetime. Adherence to the medication regimen is crucial to prevent relapse or resistance.
C. Throwing away used tissues in a closed plastic bag is correct. This is a key infection control measure to prevent the spread of tuberculosis through respiratory droplets. Used tissues should be discarded in a closed, lined container, and the client should practice good hygiene.
D. No longer infectious after 30 days of treatment is incorrect. A client with tuberculosis may remain infectious until they have completed several weeks of treatment and show improvement. Typically, a negative sputum culture is used to confirm the client is no longer infectious.
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