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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 B

Explanation

The correct answer is choice B. A client who is 1 day postoperative following a vertebroplasty. A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.

Therefore, this client is most likely to be stable and ready for early discharge.

Choice A is wrong because a client who is receiving heparin for deep-vein thrombosis (DVT) needs close monitoring of their blood levels and clotting factors. Heparin is a blood thinner that prevents the clots from getting bigger or breaking loose and traveling to the lungs, which can cause a life-threatening condition called pulmonary embolism (PE).

This client is not a good candidate for early discharge.

Choice C is wrong because a client who has cancer and a sealed implant for radiation therapy needs to be isolated in a special room to prevent exposure of others to radiation. A sealed implant is a small holder that contains a radioactive source that is placed inside or near the tumor to deliver high doses of radiation. This type of internal radiation therapy, also called brachytherapy, can last from several minutes to several days, depending on the type and dose of the radioactive source.

This client is not a good candidate for early discharge.

Choice D is wrong because a client who has COPD and a respiratory rate of 44/min has signs of respiratory distress and possible hypoxemia (low oxygen levels in the blood).

COP

A. Cross the client’s arms across their chest. B. Place the client in a high-Fowler’s position C. Hold the client’s eyes shut for a few seconds. D. Remove the client’s dentures from their mouth

Correct Answer is C

Explanation

The correct answer is choice C. Holding the client’s eyes shut for a few seconds.

This is because the eyes of a deceased client do not close naturally and may remain open after death. Holding them shut for a few seconds helps to keep them closed and prevent drying of the corneas.

This also gives a more peaceful appearance to the client’s body for the family visit.

Choice A is wrong because crossing the client’s arms across their chest is not a standard postmortem care procedure. It may also interfere with the placement of identification tags on the wrists.

Choice B is wrong because placing the client in a high-Fowler’s position is not necessary or appropriate for postmortem care. The client should be placed in a supine position with the head of the bed elevated to prevent livor mortis (purple discoloration of the skin) on the face.

Choice D is wrong because removing the client’s dentures from their mouth is not recommended for postmortem care. The dentures should be left in place to maintain the shape of the face and prevent the jaw from dropping.

Normal ranges are not applicable for this question as it does not involve any physiological measurements.

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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?