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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C: “This must be a very difficult time for you.”
Choice A rationale: Telling the parent “You didn’t do anything wrong” might seem comforting, but it doesn’t address the parent’s feelings of guilt or responsibility.It’s important to remember that myelomeningocele is a birth defect that occurs when the spine and spinal cord do not develop completely1.It’s often not known why this happens, but it can be due to a combination of genetic and environmental factors2. Therefore, it’s not something the parent did or didn’t do.
Choice B rationale: Asking “Is there any particular reason why you think this is your fault?” could potentially lead to a constructive conversation. However, it might also make the parent feel defensive or as if they need to justify their feelings. It’s crucial to approach this situation with empathy and understanding, acknowledging the parent’s feelings without making them feel judged.
Choice C rationale: Saying “This must be a very difficult time for you” is the most helpful response because it acknowledges the parent’s feelings and offers empathy. It doesn’t place blame or make assumptions. Instead, it opens up a space for the parent to express their feelings and concerns.
Choice D rationale: While it’s true that surgery can help manage the condition1, saying “With surgery, your baby should have a full recovery” might be misleading.Myelomeningocele is the most severe form of spina bifida and can cause moderate to severe disabilities, such as muscle weakness, loss of bladder or bowel control, and/or paralysis2. Each case is unique, and while some children may have less severe symptoms, others may require lifelong management. It’s important to provide accurate and realistic information.
Remember, it’s essential to approach these conversations with empathy and understanding. Parents dealing with a diagnosis of myelomeningocele are likely experiencing a range of emotions, and they need support and accurate information.
Correct Answer is A
Explanation
Tertiary prevention programs focus on minimizing the impact of an existing disease or condition and preventing further complications or disability. In the context of cardiovascular disease, one of the goals of tertiary prevention is to provide prompt rehabilitation for clients who have incurred disease complications.
By ensuring that clients who experience complications promptly receive rehabilitation services, the program is effectively addressing the needs of these clients and providing appropriate interventions to minimize the long-term impact of the disease. This outcome indicates that the program is successful in providing the necessary care and support to clients with cardiovascular disease.
Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign focuses on primary prevention rather than tertiary prevention.
At-risk clients receiving an increased number of routine health screenings may be an indicator of improved secondary prevention efforts, but it does not specifically measure the effectiveness of the tertiary prevention program for clients with cardiovascular disease.
Clients reporting new confidence in making healthy food choices is a positive outcome but does not directly reflect the effectiveness of the tertiary prevention program for cardiovascular disease.
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