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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Sit back down for a few minutes when this occurs.": This is correct. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effect. The client should be advised to sit down to prevent falls and allow the body to adjust.

B. "Take a daily potassium supplement.": This is incorrect. ACE inhibitors can increase potassium levels, and taking a potassium supplement without a healthcare provider’s recommendation may lead to hyperkalemia, a dangerous condition.

C. "Restrict your daily fluid intake.": This is incorrect. Dehydration can exacerbate hypotension, so it is not recommended to restrict fluid intake without further instructions from the provider.

D. "Discontinue this medication if this occurs again.": This is incorrect. The client should not discontinue medication without first consulting their healthcare provider. The healthcare provider may adjust the dosage or provide alternative recommendations to manage the side effects.

A. Provide informational updates to members of the media. B. Assist in discharging stable clients to home. C. Delegate tasks to emergency health care specialists. D. Determine the acuity and number of casualties arriving at the facility.

Correct Answer is B

Explanation

A. "Provide informational updates to members of the media" is incorrect. This task typically falls under the responsibility of the hospital’s public relations or communications team. Nurses do not usually handle media updates in the context of mass casualty events.

B. "Assist in discharging stable clients to home" is correct. During a mass casualty event, it is important to make room for incoming patients. Discharging stable patients helps free up beds and resources for those who need immediate care.

C. "Delegate tasks to emergency health care specialists" is incorrect. While nurses may delegate some tasks, the nurse’s primary responsibility in this scenario would be managing care within the medical-surgical unit, not directing emergency health care specialists.

D. "Determine the acuity and number of casualties arriving at the facility" is incorrect. This task is generally managed by triage teams or emergency management staff who assess incoming patients at the point of injury or arrival at the facility.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is making a follow-up call to a client who has a new prescription for an ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse working on a medical-surgical unit is notified about a mass casualty event that recently took place in the community. Which of the following assignments should the nurse anticipate?

Correct Answer is B

Explanation

A nurse is caring for a client who recently gave birth to her first child. The newborn is crying, and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients' sleep. Which of the following instructions should the nurse include?

A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?

A nurse working in a rehabilitation unit is administering medications to two clients who have the same name. Which of the following identifiers should the nurse use to verify the identities of each client?

A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect?

A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report?

A nurse is reinforcing teaching with a parent of a preschooler about immunizations. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is collecting data from a client about range-of-motion for various joints. Which of the following should the nurse identify as an example of a ball and socket joint?