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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Absence seizures are brief, sudden lapses of consciousness that usually last a few seconds. They are more common in children than in adults.
A person having an absence seizure may stare blankly into space and not respond to others. They may also have subtle movements such as lip smacking or eyelid fluttering.
Choice B is wrong because absence seizures typically last less than 15 seconds, not 30 to 60 seconds.
Choice C is wrong because absence seizures have a sudden onset, not a gradual one.
Choice D is wrong because absence seizures do not have an aura prior to onset. An aura is a warning sign that some people experience before a seizure, such as a strange feeling, smell, or vision.
Correct Answer is B
Explanation
The nurse should sit in a chair next to the bed to place the client at ease. This position allows the nurse to maintain eye contact, show interest, and respect the client’s personal space. Sitting on the bed next to the client (choice A) is wrong because it invades the client’s privacy and comfort zone. Standing at the side of the bed (choice C) or at the foot of the bed (choice D) is wrong because it creates a power imbalance and may intimidate the client.
The nurse should also consider the client’s condition and preferences when choosing a position for the interview. For example, a client who is on bedrest may have difficulty hearing or seeing the nurse if they are too far away or at an awkward angle.
Therefore, the nurse should adjust their position accordingly and ask the client if they are comfortable with it.
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.