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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. At the beginning: Examining the tympanic membrane at the beginning of the physical examination may not be ideal because it disrupts the flow of the assessment. It's more logical to start with general observations and proceed to more specific areas of assessment.
B. Before auscultating the chest and abdomen: While examining the tympanic membrane before auscultating the chest and abdomen may seem reasonable, it's not the optimal sequence. The nurse should focus on assessing major body systems before proceeding to more specific areas, such as the ears.
C. At the end: This is the correct approach. After completing the assessment of major body systems, such as the cardiovascular, respiratory, and abdominal systems, the nurse can then proceed to examine the ears, including the tympanic membrane. This sequence ensures a systematic and organized assessment.
D. Before examining the head and neck: While examining the tympanic membrane before the head and neck may seem logical due to proximity, it's more practical to conduct a comprehensive head-to-toe assessment first before focusing on specific areas like the ears.
Correct Answer is ["0.2"]
Explanation
To calculate the volume of morphine sulfate to administer, we can use the following formula:
Volume (mL) = Dose (mg) / Concentration (mg/mL)
Plugging in the known values:
- Dose = 2 mg
- Concentration = 10 mg/mL
Volume (mL) = 2 mg / 10 mg/mL
Volume (mL) = 0.2 mL
Therefore, the nurse should administer 0.2 mL of morphine sulfate per dose.
Rounded to the nearest tenth: 0.2 mL
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