A nurse is supervising a newly licensed nurse who is suctioning a client who has a tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Waits 2 min between suction passes.

Wears clean gloves during suctioning.

Turns the pressure on the suction to 200 mm Hg.

Applies suction while inserting the catheter.

Answer and Explanation

The Correct Answer is A

A. Waiting 2 minutes between suction passes allows the client to recover and helps to prevent hypoxia, demonstrating an understanding of the suctioning procedure.
B. Wearing clean gloves during suctioning is not appropriate; sterile gloves should be used to prevent introducing pathogens into the airway.
C. The recommended suction pressure for adults is typically between 80 and 120 mm Hg; therefore, setting the suction to 200 mm Hg is too high and could cause trauma to the airway.
D. Suction should be applied only while withdrawing the catheter, not while inserting it, to minimize trauma and prevent oxygen deprivation.

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Correct Answer is A

Explanation

A. Respecting the daughter's decision to refuse the transfusion aligns with the principles of patient autonomy and the authority granted through the durable power of attorney for health care, meaning the daughter's wishes must be followed.
B. Encouraging the daughter to allow the transfusion would undermine her role as the decision-maker and may cause unnecessary conflict, making this option inappropriate.
C. Discussing guardianship is not necessary or appropriate in this context, as the daughter has already been designated as the decision-maker, which negates the need for additional legal intervention.
D. Asking the provider to give consent for the transfusion contradicts the authority granted to the daughter, as she is the legally recognized decision-maker and has already made her choice.

A. Initiate oxygen therapy via nasal cannula for a client who has COPD. B. Initiate a 24-hr urine collection for a client who has end-stage kidney disease. C. Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus. D. Change the dressing for a client who has a decubitus ulcer.

Correct Answer is A

Explanation

A. Initiating oxygen therapy for a client with COPD is a priority because oxygenation is critical for clients with respiratory conditions. Hypoxia can lead to serious complications, making this intervention urgent.
B. While initiating a 24-hour urine collection is important for monitoring kidney function, it does not require immediate action compared to the need for oxygen therapy in a client with respiratory distress.
C. Administering antibiotics is essential, especially for a client with an infection like MRSA; however, the need for immediate oxygen therapy takes precedence over medication administration.
D. Changing the dressing for a decubitus ulcer is important for preventing infection and promoting healing but is not as time-sensitive as ensuring adequate oxygenation for the client with COPD.

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A nurse is supervising a newly licensed nurse who is suctioning a client who has a tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her adult daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is prioritizing care for four clients. Which of the following tasks should the nurse perform first?

Correct Answer is A

Explanation

A nurse is supervising a newly licensed nurse who is suctioning a client who has a tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

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