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D. The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C rationale:
Avoiding consuming foods containing chocolate is important for individuals with gastroesophageal reflux disease (GERD) Chocolate contains substances that can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus, worsening GERD symptoms. Therefore, the nurse should include this information in the discharge teaching to help the client manage GERD effectively.
Choice A rationale:
Taking antacids that contain mint for heartburn is not recommended. Mint can relax the lower esophageal sphincter, similar to chocolate, potentially worsening GERD symptoms. Therefore, clients with GERD should avoid mint-containing products.
Choice B rationale:
Increasing dietary intake of citrus fruits is not advisable for individuals with GERD. Citrus fruits are acidic and can irritate the esophagus, leading to increased reflux symptoms. Clients with GERD should limit or avoid citrus fruits in their diet.
Choice D rationale:
Lying down for 30 minutes after eating a meal is not a recommended practice for individuals with GERD. Instead, clients with GERD should remain upright for at least 2-3 hours after eating to reduce the risk of reflux. Lying down shortly after a meal can worsen symptoms by allowing stomach acid to flow back into the esophagus more easily.
Correct Answer is A
Explanation
A. Correct. Having regular interdisciplinary team meetings allows healthcare professionals from various disciplines to collaborate, share information, and ensure coordinated care for the client with complex needs.
B. Noting changes in the treatment plan in the client's medical record is important, but it may not directly promote effective communication among staff.
C. Recording the client's progress in the nurses' notes is essential but may not address the need for communication among the entire care team.
D. Posting swallowing precautions at the head of the client's bed is important for the client's safety but does not directly address communication among staff members.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.