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
None
None
The Correct Answer is B
A. Applying suction only during catheter removal is correct because continuous suction while inserting the catheter can cause tissue trauma and hypoxia. Intermittent suctioning during withdrawal prevents damage to the tracheal mucosa.
B. Suctioning for 30 seconds exceeds the recommended time limit, which is typically 10–15 seconds per pass for adults. Prolonged suctioning can cause hypoxia, bradycardia, and tissue trauma, making it unsafe for the client.
C. Preoxygenating with 100% oxygen before suctioning helps prevent hypoxia during the procedure. This is a standard safety measure to maintain adequate oxygen saturation levels.
D. Auscultating breath sounds before and after suctioning allows assessment of airway clearance and lung status. This step ensures that secretions have been effectively removed and helps identify any complications early.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Productive cough with pink, frothy sputum": This is a concerning finding that should prompt immediate notification to the provider. It is indicative of pulmonary edema, which can occur with left-sided heart failure as fluid backs up into the lungs. Pink, frothy sputum is a classic sign of this condition and requires urgent intervention.
B. "Weight loss of 1 kg (2.2 lB. in the past 24 hr": Weight loss is generally not a primary concern in left-sided heart failure. In fact, weight loss could be a result of fluid loss from diuretics or other interventions. A small weight change like this is not likely to be significant unless the client shows signs of dehydration or malnutrition.
C. "Fatigue when ambulating 152 m (500 ft)": Fatigue with activity is common in clients with left-sided heart failure, as reduced cardiac output and impaired oxygenation of tissues can cause fatigue during exertion. However, this is not an acute finding that would require immediate intervention.
Correct Answer is D
Explanation
A. Administering a subcutaneous insulin injection requires nursing knowledge and skill to ensure correct dosage, technique, and monitoring for side effects. This should not be delegated to an assistive personnel (AP).
B. Removing an NG tube requires nursing assessment to determine if removal is appropriate and safe for the client. It also requires skill in managing complications that may arise. This should not be delegated to an AP.
C. Providing discharge teaching about home IV medication therapy is a complex task that requires nursing knowledge about medication management, potential complications, and instructions for safe administration. It cannot be delegated to an AP.
D. Collecting a sputum culture can be delegated to an AP. This is a task within their scope of practice, provided the AP has been trained in collecting samples and the procedure is straightforward.
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