When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Wear protective goggles while performing the procedure.

Apply a water soluble lubricant to the catheter.

Instill 3 mL of normal saline before suctioning.

Instruct the client to cough as the suction tip is removed.

Answer and Explanation

The Correct Answer is A

Wearing protective goggles is important during suctioning to protect the nurse's eyes from potential splashes or aerosolized secretions. Suctioning can generate forceful coughing, gagging, or sneezing in the client, which may cause secretions or mucus to be expelled forcefully and potentially come into contact with the nurse's eyes. Wearing goggles helps prevent eye exposure and reduces the risk of infection transmission.

Applying a water-soluble lubricant to the catheter may be necessary to facilitate the insertion of the suction catheter into the tracheostomy tube, but it is not the most crucial action to include when performing suctioning.

Instilling normal saline before suctioning is not recommended as it can cause potential harm to the client's airway. Instilling saline can lead to bronchospasm, mucosal damage, and other complications. Suctioning should only be performed when necessary to remove secretions and maintain a patent airway.

Instructing the client to cough as the suction tip is removed is not necessary or recommended. Coughing during the suctioning process can be uncontrolled and may increase the risk of trauma to the airway. The nurse should instead provide supportive care and reassurance to the client throughout the procedure.

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Correct Answer is C

Explanation

Given the client's difficulty with memory, concentration, and recent life changes, it is

important for the nurse to acknowledge the possibility of delirium as a potential cause of the client's symptoms. Delirium is an acute state of confusion that can be caused by various factors, including physical illness, medication side effects, and emotional stressors. It is often reversible when the underlying cause is identified and treated.

By mentioning the possibility of delirium and its potential reversibility, the nurse opens up the conversation to exploring other factors that may be contributing to the client's symptoms. This response also provides hope to the family by suggesting that the client's condition may improve with appropriate interventions and management.

Stating that dementia resulting from Alzheimer's disease is often reversible even in the late stages is incorrect. Alzheimer's disease is a progressive neurodegenerative disorder that currently has no cure, and the symptoms tend to worsen over time.

Reversibility is not typically associated with Alzheimer's disease.

Indicating that the client's symptoms of dementia are permanent due to age is a generalization and may not be accurate. While age is a risk factor for certain types of dementia, such as Alzheimer's disease, it does not mean that all memory and cognitive difficulties in older adults are irreversible.

Suggesting that delirium is often a sign of underlying mental illness and institutionalization is necessary is not appropriate. Delirium is a medical condition that requires thorough assessment and appropriate management, including addressing any underlying causes. Institutionalization may be considered in certain situations, but it is not the primary focus of communication in this context.

Correct Answer is ["9"]

Explanation

Here are the steps you can follow to calculate the infusion pump flow rate:

Step 1: Calculate the prescribed dose in mcg/min

Dose per weight: 2 mcg/kg/min * 60 kg = 120 mcg/min

Step 2: Convert the concentration in the IV bag to mcg/mL

Convert mg to mcg: 200 mg * 1000 mcg/mg = 200,000 mcg
Concentration: 200,000 mcg / 250 mL = 800 mcg/mL

Step 3: Calculate the flow rate in mL/min

Flow rate: 120 mcg/min / 800 mcg/mL = 0.15 mL/min

Step 4: Convert the flow rate to mL/hour

Hour conversion: 0.15 mL/min * 60 min/hour = 9 mL/hour

Therefore, the nurse should program the infusion pump to deliver 9 mL/hour.

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When performing suctioning for a client with a tracheostomy, which action should the nurse include?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The healthcare provider prescribes dopamine 2 mcg/kg/min intravenously (IV) for client who weighs 60 kg. The IV bag contains dopamine 200 mg in dextrose 5% in water (DW) 250 mL. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numerical value only.)

Correct Answer is ["9"]

Explanation

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