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D. The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Mild swelling under the sutures is a common finding after surgery and may not necessarily require reporting unless it worsens or is associated with other concerning symptoms.
B. Incorrect. Pink-tinged coloration can be a normal part of the healing process, as long as there is no excessive redness, warmth, or signs of infection.
C. Incorrect. Crusting of exudate on the incisional line can occur during the healing process and may not necessarily indicate a problem unless it's accompanied by signs of infection.
D. Correct. Partial separation of the upper part of the incisional line can indicate wound dehiscence, a potential complication that requires immediate attention to prevent infection and further complications.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
Explanation
Serotonin syndrome: This is a potentially life-threatening condition caused by an excess of serotonin in the brain. It can occur when there is an increase in the dose of an SSRI or when a new SSRI is introduced, particularly if the client has recently been on another SSRI, as in this case where fluoxetine was switched to paroxetine.
Selective serotonin reuptake inhibitors (SSRIs): Both fluoxetine and paroxetine are SSRIs. The risk of serotonin syndrome increases with changes or increases in the dosage of SSRIs due to the potential for excessive serotonin levels.
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