An infant client has a tracheostomy. The nurse prepares to suction the tracheostomy. Which most important principle does the nurse use to plan care?

Suctioning must follow a set schedule every two hours

Coughing helps loosen secretions before suctioning

A strict sterile technique is always required for suctioning

Suction pressure time and catheter size are critical

Answer and Explanation

The Correct Answer is D

It is important to use the appropriate suction pressure, time, and catheter size when suctioning a tracheostomy to prevent injury and ensure eﬀective removal of secretions.

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Correct Answer is A

Explanation

This is because the outcome of the plan is for the client to learn self-glucose testing, which implies that the client can perform the testing correctly on their own. Option A shows that the client has successfully learned and can perform the skill independently, which is the ultimate goal of the plan.

Option B, "Client says 'I can do the testing now'," and option C, "Client explains the testing process to the nurse," may show that the client has some understanding of the testing process, but they do not demonstrate that the client can perform the skill independently.

Option D, "Client observes the nurse test glucose 5 times," is not an appropriate method for evaluating the client's ability to perform self-glucose testing. Observing the nurse perform the skill does not demonstrate that the client has learned the skill themselves.

A. Assesses the IV site for inﬂammation B. Measures the urine output for the day C. Calls the partner to come and visit D. Asks the client if pain medication is required

Correct Answer is C

Explanation

The client is likely feeling scared, vulnerable, and alone. By calling the partner to come and visit, the nurse can provide the client with emotional support and comfort during this difficult time. This can also help to alleviate the client's distress and promote a sense of security and familiarity.

Assessing the IV site for inﬂammation (a) and measuring the urine output for the day (b) are important aspects of the client's care, but they are not the priority in this situation. Asking the client if pain medication is required (d) is also important, but it can wait until the client's emotional needs have been addressed.

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An infant client has a tracheostomy. The nurse prepares to suction the tracheostomy. Which most important principle does the nurse use to plan care?

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Naxlex Comprehensive Predictor Exams

The nurse evaluates a client's plan of care. The client has an outcome of 'Client will learn self-glucose testing before discharge'. When evidence best allows the nurse to meet the outcome of the plan?

Correct Answer is A

Explanation

A young adult client has a partner and no children. The client has a hysterectomy because of endometrial cancer. The client has an IV and an indwelling urinary catheter. The client is crying asking for their partner. Which action does the nurse take first?

Correct Answer is C

Explanation

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