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. 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.
Correct Answer is A
Explanation
A. Dry the skin: The priority nursing action immediately following birth is to ensure the newborn's warmth. Drying the newborn's skin helps prevent hypothermia, which is a significant risk for neonates. The nurse should dry the newborn's skin using a warm, dry towel to prevent heat loss through evaporation.
B. Administer vitamin K: Administering vitamin K is an important procedure shortly after birth to prevent hemorrhagic disease of the newborn. However, ensuring warmth by drying the skin takes precedence over administering vitamin K as the newborn's temperature regulation is crucial immediately after delivery.
C. Place an identification bracelet: Placing an identification bracelet on the newborn is essential for proper identification and security purposes, but it is not the priority immediately after birth. Ensuring the newborn's warmth and maintaining physiological stability take precedence.
D. Administer eye prophylaxis: Administering eye prophylaxis, typically in the form of erythromycin ointment or another antimicrobial agent, is important to prevent neonatal conjunctivitis due to exposure to maternal pathogens during delivery. However, this intervention can wait until after the newborn's warmth is ensured through drying the skin.
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