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D.   The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.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 B

Explanation

Among the given assessment findings, the one that warrants the most immediate intervention by the nurse is the shortness of breath on exertion. Shortness of breath on exertion in a client with a history of chronic obstructive pulmonary disease (COPD) and pneumonia indicates increased respiratory distress and compromised lung function. It suggests that the client is experiencing difficulty breathing even with minimal physical exertion. This finding may indicate worsening respiratory status, increased oxygen demand, and inadequate oxygenation. The nurse should take immediate action to address the shortness of breath, which may involve providing supplemental oxygen, initiating or adjusting bronchodilator medications, and monitoring the client's respiratory status closely. Prompt intervention is crucial to ensure adequate oxygenation and prevent respiratory failure.

While the other assessment findings (bilateral diffuse wheezing, temperature of 100.5 °F, and yellow expectorated sputum) are also important and require attention, the shortness of breath on exertion poses the greatest immediate risk and necessitates immediate intervention to address the client's respiratory distress.

A. Educate the family to avoid sharing personal belongings. B. Ensure the state health department has been notified. C. Administer antitoxin. D. Assess for skin necrosis.

Correct Answer is B

Explanation

A. Lyme disease is primarily transmitted through ticks.

B. Lyme disease is a communicable disease of public concern and hence reportable

C. Incorrect. Antitoxin is not used for treating Lyme disease. Lyme disease is caused by a bacterium, not a toxin.

D. Incorrect. Skin necrosis is not a common manifestation of Lyme disease. The primary symptoms include fever, fatigue, headache, and a characteristic skin rash known as erythema migrans.

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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

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