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 C

Explanation

A. Tonic-clonic seizures: This is not typically expected following electroconvulsive therapy (ECT). ECT can induce a brief seizure during the procedure, but the nurse would not expect tonic-clonic seizures afterward as a direct result.

B. Paresthesias: Paresthesias (tingling or numbness) are not commonly associated with ECT. The procedure primarily affects the brain, and while some neurological symptoms may occur temporarily, paresthesias are not expected findings.

C. Disorientation: This is correct. It is common for clients to experience disorientation and confusion immediately following ECT, as it can affect memory and cognition temporarily. This typically resolves within a short period of time (minutes to hours) following the procedure.

D. Sleep apnea: Sleep apnea is not a direct or common effect of ECT. While anesthesia used during the procedure may cause some temporary respiratory changes, sleep apnea would not be expected as a typical post-procedure finding.

A. "You can take a stool softener to prevent constipation." B. "You can remove your eye patch during the day." C. "You should bend from the waist to pick up objects." D. "You can apply a warm, moist compress to your forehead to reduce pain."

Correct Answer is A

Explanation

A. "You can take a stool softener to prevent constipation." is correct. After a retinal detachment repair, clients should avoid straining during bowel movements, as increased intracranial pressure could affect the healing eye. Taking a stool softener is a helpful preventive measure to avoid constipation.

B. "You can remove your eye patch during the day." is incorrect. The eye patch should typically be worn continuously to protect the eye and support healing. The surgeon's specific instructions should be followed regarding when the patch can be removed.

C. "You should bend from the waist to pick up objects." is incorrect. After retinal surgery, clients should avoid bending from the waist as this can increase intraocular pressure, potentially compromising the surgical repair. Instead, clients should use proper body mechanics and bend at the knees.

D. "You can apply a warm, moist compress to your forehead to reduce pain." is incorrect. Applying a warm compress to the forehead is not typically recommended following a retinal repair. Clients should follow the specific post-operative instructions from the surgeon, which may include cold compresses or other methods of managing discomfort.

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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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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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