A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

Waits for 2 min between suctions

Applies suction for 15 seconds

Encourages the client to cough during suctioning

Inserts the catheter without applying suction

None

Answer and Explanation

The Correct Answer is C

A.   Waiting for 2 minutes between suctions is a standard practice to prevent damage to the trachea and to allow the client to recover from the suctioning process. This action is also appropriate and does not require intervention.
B.   Suction is typically applied for 10-15 seconds while withdrawing the catheter to prevent hypoxia and trauma to the airway.
C.   Encouraging a client to cough during suctioning is generally acceptable because coughing helps expel secretions from the airway.However, the nurse should ensure that the client does not cough too forcefully, as this could lead to trauma or discomfort.
D.   The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.

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Correct Answer is A

Explanation

A. Correct. Scrambled eggs and toast are generally kosher-friendly options. However, milk may not be suitable if the client keeps kosher dietary laws, as it cannot be mixed with meat in the same meal.

B. Incorrect. Bacon and cheese quiche contain pork (bacon), which is not kosher.

C. Incorrect. Ham is pork and is not considered kosher.

D. Incorrect. Shrimp and milk are not kosher foods.

A. Provide oral hygiene care. B. Administer an antiemetic medication. C. Replace the NG tube. D. Evaluate the functioning of the suction device.

Correct Answer is D

Explanation

A. Incorrect. Providing oral hygiene care is important but not the first priority after a client has vomited

B. Incorrect. While administering an antiemetic medication might be considered, providing oral hygiene care to the client is the immediate priority.

C. Incorrect. Replacing the NG tube is not typically the first action to take after a client vomits. Addressing oral hygiene and assessing the client's condition comes first.

D. Correct. Evaluating the functioning of the suction device is important as it helps to prevent aspiration of contents.

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A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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