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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Tinnitus with ear pain: While tinnitus can be a side effect of some medications, it is not associated with Stevens-Johnson syndrome (SJS). This symptom is more common with other medications or conditions, like aspirin or certain antibiotics, but not allopurinol.

B. Diplopia: Diplopia (double vision) is not a common sign of Stevens-Johnson syndrome. This symptom could be related to other conditions but is not characteristic of SJS.

C. Hyperreflexia: Hyperreflexia is not a typical manifestation of Stevens-Johnson syndrome. While neurological symptoms may sometimes occur, they are not central to the diagnosis of SJS.

D. Skin rash with fever: A skin rash with fever is a classic early sign of Stevens-Johnson syndrome. It is a potentially life-threatening reaction to certain medications, including allopurinol, and requires immediate medical attention. The rash often begins with a mild erythema, which may progress to blistering and sloughing of the skin.

A. Physical therapist B. Primary care provider C. Occupational therapist D. Social worker

Correct Answer is D

Explanation

A. Referring to a physical therapist is incorrect. Physical therapists focus on improving mobility, strength, and balance, but they do not typically assist with transportation needs or alternative arrangements for follow-up appointments.

B. Referring to a primary care provider is incorrect. While the primary care provider oversees medical care and follow-ups, they do not arrange transportation services or address logistical concerns regarding appointments.

C. Referring to an occupational therapist is incorrect. Occupational therapists help clients regain skills for daily living, including adaptive techniques for driving, but they do not arrange transportation.

D. Referring to a social worker is correct. Social workers help clients identify resources, such as transportation services, to ensure they can attend medical appointments and access necessary care.

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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

A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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