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 D
Explanation
Sharing personal passwords for accessing electronic client records is a violation of healthcare privacy and security regulations, such as the Health Insurance Portability and Accountability Act (HIPAA). Personal passwords should never be shared with anyone, regardless of their role or position within the healthcare facility. Each individual accessing electronic records should have their own unique login credentials to maintain accountability and protect the confidentiality of client information.
A. The nurse manager: While the nurse manager may have legitimate reasons to access client records, they should do so using their own authorized credentials. Sharing passwords compromises security and accountability.
B. A nursing student who is completing a preceptorship on the unit: Nursing students should be provided with their own temporary login credentials or supervised access to client records as part of their educational experience. Sharing personal passwords with students is inappropriate and violates privacy regulations.
C. The unit clerk: Unit clerks may require access to certain client information for administrative purposes, but they should have their own authorized login credentials provided by the facility. Sharing passwords with non-clinical staff like unit clerks poses risks to client privacy and confidentiality.
D. No one: This option is the correct choice. Personal passwords should never be shared with anyone, as doing so compromises security, violates privacy regulations, and undermines accountability for accessing electronic client records.
Correct Answer is C
Explanation
A. Tell the child it is candy: Deceiving the child by telling them medication is candy can lead to trust issues and may cause confusion if the child later discovers the truth. It's important to promote honesty and transparency in healthcare interactions.
B. Tell the child he will have to have a shot instead: Threatening the child with a shot as an alternative to taking medication can induce fear and anxiety, making the child more resistant to cooperation. Using fear as a motivator can have negative psychological effects and should be avoided.
C. Offer the child a choice of taking the medication with juice or water: This strategy empowers the child by giving them a sense of control and autonomy over the situation. Offering choices can help the child feel more involved in their care and increase cooperation. By allowing the child to choose how they take the medication, they may be more willing to comply.
D. Hide the medication in a large dish of ice cream: While hiding medication in food may be effective for some children, it can undermine trust if the child discovers the deception. Additionally, this method does not teach the child how to take medication independently and may not be feasible in all situations. Offering choices and involving the child in the decision-making process is a more respectful and effective approach.
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