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D. The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.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 C
Explanation
A.Jogging or any form of vigorous exercise, especially high-impact activities, should generally be avoided for at least 4–6 weeks after retinal surgery. This is because high-impact activities can increase intraocular pressure and potentially disrupt the healing retina. Jogging involves bouncing or jolting movements, which could adversely affect the repair.
B. Bending at the waist places increased pressure on the eye and can disrupt the healing process after retinal surgery. This action increases intraocular pressure and is typically discouraged postoperatively.
C. Light lifting, such as lifting objects under 10 pounds, is typically allowed after several weeks of recovery, once the initial healing has occurred and the client is no longer at risk for increasing intraocular pressure or straining the surgical site.
D. While sewing itself is a low-impact activity, the act of sewing typically involves bending over or placing the head below the waist, which could still increase intraocular pressure. Early postoperative instructions often caution against activities that involve bending or straining the eyes, such as sewing, reading, or watching TV for extended periods.
D. Correct. After surgical repair of a detached retina, clients should avoid activities that might increase intraocular pressure, like heavy lifting or bending at the waist. Activities that do not strain the eye, like sewing, can typically be resumed earlier.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The client is experiencing preterm contractions, which may indicate the onset of preterm labor. The cervical dilation and effacement, along with the history of a previous preterm birth, raise concerns about the potential for another preterm birth. These findings require further assessment and monitoring by the healthcare provider.
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