nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps, placing them in the selected order of performance. Use all the steps.)
Lubricate the catheter with sterile saline.
Insert the catheter until resistance is felt.
Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in).
Rotate the catheter while suctioning.
The Correct Answer is A,B,C,D
A. Lubricate the catheter with sterile saline: Lubrication reduces friction and trauma to the tracheal mucosa during insertion, facilitating smoother catheter advancement and minimizing irritation.
B. Insert the catheter until resistance is felt: The catheter is advanced gently until the first point of resistance, which indicates proximity to the carina or a main bronchus. This prevents excessive insertion that could injure airway structures.
C. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in): Withdrawing slightly before applying suction helps avoid direct trauma to the carina while still targeting secretions in the larger airways for effective clearance.
D. Rotate the catheter while suctioning: Rotating the catheter while applying suction maximizes removal of secretions from the trachea and bronchi while distributing suction forces evenly, reducing the risk of mucosal injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Fentanyl: Fentanyl is a potent opioid typically reserved for severe, acute, or chronic pain such as in surgical or cancer-related conditions. It is not commonly used for moderate pain in stable orthopedic cases like a simple fracture.
B. Aspirin: Aspirin is a mild analgesic and anti-inflammatory. It may help with mild pain but is inadequate for moderate pain rated 7/10. Additionally, its antiplatelet effects can increase bleeding risk, especially post-trauma.
C. Hydrocodone: Hydrocodone is an opioid analgesic appropriate for managing moderate to severe pain, such as that caused by a fracture. It is commonly used in combination with acetaminophen and is suitable for a pain rating of 7/10.
D. Acetaminophen: Acetaminophen is effective for mild to moderate pain but may not provide sufficient relief for pain rated at 7/10. It is often used adjunctively but would not be the primary choice in this scenario.
Correct Answer is D
Explanation
A. Maintenance: The maintenance stage occurs after a new behavior has been sustained for an extended period, typically six months or more. At this stage, the focus is on preventing relapse rather than actively implementing change.
B. Preparation: The preparation stage involves planning to take action within the near future, such as gathering resources or developing a plan. The behavior has not yet been implemented, which differs from the scenario described.
C. Contemplation: Contemplation is the stage in which individuals are aware of a problem and are thinking about making a change but have not yet committed to action. The group in this scenario has moved beyond mere consideration.
D. Action: The action stage is characterized by active implementation of strategies to modify behavior. Since the group is actively reducing pesticide use in the community gardens, they are engaged in the action stage of change.
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