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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Raisin toast is a bland carbohydrate that is generally well-tolerated and can help settle the stomach, making it a suitable choice for clients experiencing chemotherapy-induced nausea.
B. Soft-serve ice cream may be too rich and can upset the stomach for some clients undergoing chemotherapy, leading to increased nausea.
C. String cheese is high in fat and protein, which might not be well-tolerated during episodes of nausea, as heavy foods can exacerbate discomfort.
D. Hot tea may be soothing for some clients; however, certain herbal teas can sometimes provoke nausea or have an adverse effect, making it less ideal than bland carbohydrates.
Correct Answer is A
Explanation
A. Autonomy refers to the right of individuals to make their own decisions regarding their healthcare, including the right to refuse treatment, which the nurse has supported in their response.
B. Fidelity involves being faithful to commitments made to patients, such as providing care and support, but does not directly pertain to the client's right to refuse treatment.
C. Beneficence focuses on promoting the well-being of the client, which may not align with the client’s decision to refuse treatment in this context.
D. Justice refers to fairness in healthcare and ensuring equitable treatment, but it does not address the specific right of the client to refuse treatment.
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