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?

Inserts the catheter without applying suction.

Waits for 2 min between suctions.

Applies suction for 15 seconds.

Encourages the client to cough during suctioning.

Answer and Explanation

The Correct Answer is C

The correct answer is **c. Applies suction for 15 seconds**.

**Choice A rationale:** Inserting the catheter without applying suction is a proper step in the suctioning process. This action does not require intervention by the staff nurse.

**Choice B rationale:** 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.

**Choice C rationale:** Applying suction for 15 seconds is too long and can cause damage to the trachea. The recommended duration for suctioning is typically 5-10 seconds. This action requires intervention by the staff nurse to correct the procedure and ensure the client's safety.

**Choice D rationale:** Encouraging the client to cough during suctioning is a proper step to help clear the trachea and promote effective suctioning. This action does not require intervention by the staff nurse.

In summary, the newly licensed nurse's action of applying suction for 15 seconds is the one that requires intervention by the staff nurse to correct the procedure and ensure the client's safety.

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Correct Answer is A

Explanation

A thoracentesis is a procedure that involves inserting a needle into the pleural space to remove excess fluid or air. Coughing can increase the risk of pneumothorax (collapsed lung) or bleeding during the procedure.

Choice B is wrong because the client does not need to be NPO (nothing by mouth) for 6 hr prior to the procedure. There is no risk of aspiration during a thoracentesis.

Choice C is wrong because the client should be positioned on the unaffected side for 4 hr following the procedure. This allows the affected lung to re-expand and prevents fluid from accumulating in the pleural space again.

Choice D is wrong because the client should not be placed in the prone position during the procedure. The prone position makes it difficult to access the pleural space and can compromise breathing.

A. "I will eat fish for dinner at least twice per week.". B. "I will limit my morning coffee to no more than two cups.". C. "I will eat small, frequent meals.". D. "I should expect my bowel movements to be pale in color". E. "I will notify my provider if my urine is dark.".

Correct Answer is ["C"]

Explanation

“I will eat small, frequent meals.”.

This statement indicates an understanding of the discharge teaching because eating small, frequent meals can help reduce the workload of the pancreas and prevent pain and nausea.

“I will eat fish for dinner at least twice per week.” This statement does not indicate an understanding of the discharge teaching because fish is a high-fat food that can aggravate pancreatitis. The client should eat a low-fat diet with no more than 30 grams of fat per day.

“I will limit my morning coffee to no more than two cups.” This statement does not indicate an understanding of the discharge teaching because coffee is a caffeinated beverage that can stimulate the pancreas and worsen inflammation. The client should avoid caffeine and alcohol.

D. “I should expect my bowel movements to be pale in color”. This statement does not indicate an understanding of the discharge teaching because pale stools can be a sign of bile duct obstruction or pancreatic insufficiency, which are complications of pancreatitis. The client should notify the provider if they notice any changes in their stool color or consistency.

E. “I will notify my provider if my urine is dark.” This statement does not indicate an understanding of the discharge teaching because dark urine can be a sign of dehydration or jaundice, which are also complications of pancreatitis. The client should drink plenty of fluids and monitor their skin and eyes for yellowing.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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Correct Answer is ["C"]

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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?