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
None
None
The Correct Answer is B
The correct answer is choice b. Waits for 2 min between suctions.
Choice A rationale:
Inserting the catheter without applying suction is correct. Suction should only be applied while withdrawing the catheter to prevent trauma to the tracheal mucosa.
Choice B rationale:
Waiting for 2 minutes between suctions is too long. The appropriate wait time is generally around 20-30 seconds to 1 minute between suction attempts to prevent hypoxia and allow the patient to recover.
Choice C rationale:
Applying suction for 15 seconds is within the recommended duration. Suctioning should not exceed 15 seconds to avoid causing hypoxia and trauma to the tracheal mucosa.
Choice D rationale:
Encouraging the client to cough during suctioning is appropriate. Coughing helps to mobilize secretions and can make suctioning more effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Increase dietary calcium. Prednisone is a corticosteroid medication that can cause bone loss (osteoporosis) by reducing the absorption of calcium and increasing the excretion of calcium in the urine. Therefore, patients taking prednisone should increase their intake of calcium-rich foods or supplements to prevent bone loss and fractures.
Choice B is wrong because prednisone can cause weight gain, not weight loss, by increasing appetite and fluid retention. Patients taking prednisone should monitor their weight and limit their salt and calorie intake.
Choice C is wrong because prednisone should not be taken on an empty stomach, as it can cause stomach irritation, ulcers, or bleeding. Patients taking prednisone should take it with food or milk to protect their stomach.
Choice D is wrong because prednisone should not be scheduled at bedtime, as it can cause insomnia or difficulty sleeping. Patients taking prednisone should take it in the morning or early afternoon to avoid disrupting their sleep cycle.
Correct Answer is A
Explanation
The correct answer is A. Beneficence. Beneficence is the ethical principle of doing good for the patient and promoting their well-being.
The nurse is demonstrating beneficence by sitting with the client to provide comfort and support during a difficult time.
Choice B is wrong because fidelity is the ethical principle of keeping promises to the patient and being loyal and faithful.
The nurse is not making or keeping any promises to the client in this scenario.
Choice C is wrong because autonomy is the ethical principle of respecting the patient’s right to make their own decisions and choices.
The nurse is not interfering with the client’s autonomy in this scenario.
Choice D is wrong because veracity is the ethical principle of telling the truth to the patient and being honest and trustworthy.
The nurse is not lying or withholding information from the client in this scenario.
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