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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?

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

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice C. Wear loose-fitting underwear. This is because tight-fitting underwear can trap moisture and create a favorable environment for bacterial growth, which can increase the risk of urinary tract infections (UTIs) . Loose-fitting underwear can allow air circulation and prevent moisture accumulation .

Choice A is wrong because drinking four 240 mL (8 oz) glasses of water each day is not enough to prevent UTIs. The recommended amount of water intake for adults is about 2 to 3 liters per day . Drinking enough water can help flush out bacteria from the urinary tract and prevent them from adhering to the bladder wall .

Choice B is wrong because voiding every 5 to 6 hours during the day is too infrequent and can increase the risk of UTIs. The nurse should advise the client to void every 2 to 3 hours during the day . This can help prevent urinary stasis and bacterial multiplication in the bladder .

Choice D is wrong because taking a bubble bath after intercourse can increase the risk of UTIs. The nurse should instruct the client to avoid bubble baths, vaginal douches, or sprays, as they can irritate the urethra and introduce bacteria into the urinary tract . The nurse should also advise the client to empty the bladder before and after sexual intercourse, as this can help remove bacteria that may have entered the urethra during sexual activity

A. Atrial fibrillation B. First-degree AV block C. Premature ventricular contraction D. Sinus bradycardia

Correct Answer is B

Explanation

The correct answer is B.

Choice A reason: Atrial fibrillation is characterized by a rapid, irregular heartbeat and an absence of distinct P waves on the ECG, which is not indicated by the information provided.

Choice B reason: First-degree AV block is indicated by a prolonged PR interval without affecting the overall heart rate, aligning with the client’s PR interval of 0.24 seconds.

Choice C reason: Premature ventricular contraction would show an abnormal QRS complex on the ECG, which is not mentioned in the scenario.

Choice D reason: Sinus bradycardia is defined by a heart rate less than 60 bpm, which does not apply here as the client’s heart rate is 69/min, within the normal range of 60-100 bpm.

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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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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?