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 D

Explanation

A) Incorrect - Skin redness might indicate irritation, but the initial focus should be on the client's sensation.
B) Incorrect - Decreasing the strength of the electrical signals might be premature if the sensation is normal.
C) Incorrect - The amount of gel coating on the electrodes might not be the primary issue if the client is feeling a tingling sensation.
D) Correct- A tingling sensation is normal and expected when using a TENS unit, and it does not indicate any harm or damage to the skin or nerves. However, the sensation should not be painful or unpleasant for the client, and the nurse should adjust the intensity of the electrical signals accordingly.

A. Phototherapy B. Administration of lithium C. Consciousness-raising D. Cognitive behavioral therapy E. Animal therapy F. Electroconvulsive therapy

Correct Answer is ["D","E"]

Explanation

A) Incorrect - Phototherapy, often used to treat conditions like seasonal affective disorder (SAD) or certain skin conditions, involves exposure to specific wavelengths of light. It is not typically used as a treatment for distressing thoughts and memories related to trauma, as described in the client's situation.
B) Incorrect - Lithium is primarily used to treat bipolar disorder and is not a first-line treatment for trauma-related symptoms or acute stress disorder. The client's symptoms are more indicative of trauma-related distress, which would be addressed through psychotherapeutic approaches like cognitive behavioral therapy (CBT).
C) Incorrect - "Consciousness-raising" is not a recognized treatment intervention in this context.

It's important to focus on evidence-based therapeutic approaches for trauma-related symptoms, such as psychotherapy and support services.
D) Correct - Cognitive behavioral therapy (CBT) is Given the client's distressing thoughts and memories, CBT is a highly effective psychotherapy approach. It focuses on identifying and modifying negative thought patterns and behaviors associated with trauma. CBT can help the client develop healthier coping strategies.
E) Correct - Animal-assisted therapy involves interacting with trained animals to improve emotional well-being. Since the client expresses feeling unhappy and having difficulty coping, animal therapy can provide comfort, reduce stress, and promote a sense of companionship.
F) Incorrect - Electroconvulsive therapy (ECT) is a treatment primarily used for severe cases of depression or certain psychiatric conditions that are unresponsive to other treatments. It involves inducing controlled seizures to affect brain chemistry. ECT is not a first-line treatment for the client's distressing thoughts and memories following a traumatic event.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?

Correct Answer is D

Explanation

Patient Data What other treatments might be helpful for this client? Select all that apply.

Correct Answer is ["D","E"]

Explanation

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