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A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Lubricate the suction catheter tip with sterile saline

Suction two to three times with a 50-second pause between passes

Hyperventilate the client on 100% oxygen prior to suctioning

Perform chest physiotherapy prior to suctioning

None

Answer and Explanation

The Correct Answer is C

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

A. Lubricate the catheter with water-soluble gel.
Lubrication is important to reduce urethral trauma, but this is not the first step once the sterile field is prepared. It comes after draping and cleansing, just before catheter insertion.

B. Position the sterile drape leaving the perineum exposed.
This is the first action after donning sterile gloves and preparing the field. Draping maintains a sterile environment and provides access to the insertion site. Ensuring sterility from the beginning is critical for preventing catheter-associated infections.

C. Cleanse the client’s meatus with antiseptic solution.
Cleansing the meatus is done after draping to reduce the risk of introducing microorganisms during catheter insertion. Although essential, it is not the very first step once the sterile procedure begins.

D. Attach a prefilled syringe to the catheter inflation hub.
The balloon should not be prepared or inflated until after the catheter has been inserted and urine return is observed. Attaching the syringe too early may risk accidental inflation outside the bladder.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Instruct the client to stay in the same position for 2 min: While it is important for the client to remain in a supine position with the head tilted back slightly after instilling nasal decongestant drops, there is no need for the client to remain in the same position for a specific duration such as 2 minutes.
B. Tell the client to blow her nose gently before the instillation: Blowing the nose before instilling nasal decongestant drops is not necessary and may cause irritation to the nasal passages. The drops should be instilled directly into the nasal passages without prior blowing of the nose.
C. Assist the client to a side-lying position: There is no need to assist the client to a side-lying position for the administration of nasal decongestant drops. The drops are typically administered with the client in a seated or supine position with the head tilted back slightly.
D. Hold the dropper 2 cm (1 in) above the nares: This is the correct action. Holding the dropper approximately 2 cm (1 in) above the nares allows for precise instillation of the drops into the nasal passages without touching the dropper to the nares, which helps prevent contamination.

A. Take the medication with meals. B. Check the pulse after medication administration. C. Limit caffeine intake. D. Rinse the mouth after administration.

Correct Answer is D

Explanation

A. Take the medication with meals: Beclomethasone is an inhaled corticosteroid used to prevent asthma symptoms. It should be taken as prescribed by the healthcare provider, usually inhaled at specific times each day. Taking the medication with meals is not necessary, as it does not affect its efficacy or absorption.
B. Check the pulse after medication administration: Checking the pulse is not typically indicated after administering inhaled beclomethasone. Beclomethasone is a corticosteroid inhaler used for long-term control of asthma symptoms and is not associated with significant cardiovascular effects that would necessitate pulse monitoring.
C. Limit caffeine intake: Limiting caffeine intake is not specifically related to the administration of inhaled beclomethasone. However, caffeine can exacerbate some asthma symptoms in susceptible individuals, so general advice to limit caffeine intake may be beneficial for managing asthma symptoms overall. Still, it's not directly related to the administration of this medication.
D. Rinse the mouth after administration: This is the correct action. Inhaled corticosteroids like beclomethasone can cause local side effects such as oral candidiasis (thrush) or dysphonia (hoarseness) due to deposition of the medication in the mouth and throat. Rinsing the mouth with water after each dose helps minimize these side effects by reducing the amount of medication left in the mouth, thereby decreasing the risk of oral candidiasis and other local adverse effects.

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A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. Which of the following instructions should the nurse provide?

Correct Answer is D

Explanation

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