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
None
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D. The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.
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Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Teaching the client to tighten a muscle group, release the tension, and then move to the next one is a technique used in progressive muscle relaxation (PMR) PMR is a stress management technique that involves tensing and relaxing different muscle groups to reduce muscle tension and promote relaxation. This method helps individuals become more aware of the sensations associated with muscle tension and relaxation, making it an effective strategy for managing anxiety and stress.
Choice A rationale:
Thinking about a positive outcome to a stressful situation is a cognitive-behavioral technique that can help shift the client's focus from negative thoughts to positive ones. While this technique can be beneficial, it does not specifically pertain to progressive relaxation as described in choice B.
Choice C rationale:
Picturing taking the stress and pushing it out of the feet is a visualization technique, which can be helpful for some individuals in managing stress. However, it is not a component of progressive relaxation as described in choice B.
Choice D rationale:
Focusing on a pleasant memory and expressing emotions in writing is a form of journaling or expressive writing, which can be a therapeutic technique for managing emotions and stress. While it can be a helpful strategy, it is not the same as progressive relaxation involving muscle tension and release.
Correct Answer is D
Explanation
A. Incorrect. Postural drainage is usually performed multiple times a day, usually three to four times, to effectively mobilize respiratory secretions.
B. Incorrect. Percussions are typically performed using cupped hands to create vibrations. Holding the hand flat would not produce the desired effect.
C. Bronchodilator should be administered PRIOR to procedure if prescribed
D. Postural drainage should be performed before meals or at least 1-2 hours after meals to prevent vomiting or aspiration.
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