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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 A

Explanation

A. Apply 4 to 5 ml of liquid soap to the hands: This is the correct action. Applying an adequate amount of soap ensures effective cleaning of the hands. The recommended amount is typically 3 to 5 ml or enough to cover the entire surface of the hands.
B. Hold the hands higher than the elbows: This is incorrect. When performing hand hygiene, the hands should be held lower than the elbows to prevent water from running down the arms and contaminating previously cleaned areas.
C. Rub hands and arms to dry: This is incorrect. After washing the hands, they should be dried using a clean paper towel or air dryer. Rubbing hands and arms to dry is not recommended as it can lead to friction and potential skin irritation.
D. Adjust the water temperature to feel hot: This is incorrect. The water temperature should be warm, not hot, to prevent skin damage or discomfort. Hot water can strip the skin of its natural oils and lead to dryness or irritation.

A. The AP's ability to complete the task without assistance B. The AP's rapport with clients C. The AP’s ability to prioritize D. The AP has the knowledge and skill to perform the task

Correct Answer is D

Explanation

A. The AP's ability to complete the task without assistance: While it's important for the AP to be able to complete the task independently, this is not the only consideration when delegating tasks. The nurse should also consider whether the AP has the necessary knowledge and skill to perform the task safely and effectively.
B. The AP's rapport with clients: Although the AP's rapport with clients is valuable in providing care, it is not directly related to the ability to perform a delegated task. The nurse should prioritize delegation based on the AP's competency and skill level rather than their interpersonal skills.
C. The AP’s ability to prioritize: While the AP's ability to prioritize tasks is important in providing efficient care, it is not specifically related to the nurse's consideration when delegating tasks. Delegation decisions should primarily be based on the AP's knowledge and skill to perform the task safely and effectively.
D. The AP has the knowledge and skill to perform the task: This is the most appropriate consideration when delegating tasks. Ensuring that the AP has the necessary knowledge and skill to perform the delegated task safely and effectively is essential for patient safety and quality care. The nurse should assess the AP's competency and provide appropriate supervision and guidance as needed.

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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

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Explanation

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