11. A 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 into the box, placing them in the selected order of performance. Use all the steps.)
Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in).
Insert the catheter until resistance is felt.
Lubricate the catheter with sterile saline.
Rotate the catheter while suctioning.
The Correct Answer is C,B,A,D
C. Lubricate the catheter with sterile saline. After donning sterile gloves, the nurse should lubricate the catheter to reduce friction and prevent trauma to the tracheal mucosa during insertion.
B. Insert the catheter until resistance is felt. The catheter should be gently inserted into the tracheostomy until resistance is met, indicating that it has reached the carina. Inserting beyond this point may cause injury.
A. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in). Pulling back slightly after resistance ensures the catheter is not pressing directly on sensitive structures and is positioned correctly for effective suctioning.
D. Rotate the catheter while suctioning. Suction should be applied while withdrawing the catheter in a rotating motion to evenly clear secretions and minimize damage to the tracheal lining.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client who has a fracture and is in balance suspension traction. This client is non-ambulatory and difficult to move quickly, so should not be evacuated first unless they are in immediate danger. They would require additional assistance and equipment to move safely.
B. A client who is ambulatory and receiving oxygen. This client is able to walk independently and can evacuate with minimal assistance, even while on oxygen. Evacuating ambulatory clients first helps clear the area quickly and frees up staff to assist less mobile clients.
C. A client who uses a wheelchair and is confused. While this client needs help due to confusion and mobility limitations, they are not the priority for first evacuation unless in immediate danger. They require more time and assistance.
D. A client who is bedridden and wears a hearing aid. This client is non-ambulatory and may have communication challenges, which makes evacuation more complex. They would be evacuated after ambulatory clients for safety and efficiency.
Correct Answer is A
Explanation
A. "Rise slowly when getting out of bed." Furosemide can lead to significant fluid and electrolyte loss, causing orthostatic hypotension. Clients may experience dizziness or lightheadedness when changing positions. Rising slowly helps prevent falls and promotes safety.
B. “Taking furosemide can cause you to be overhydrated." Furosemide is a potent diuretic that promotes fluid excretion, not retention. The risk of dehydration and electrolyte imbalance is much higher than overhydration. Monitoring intake and output is essential.
C. "Eat foods that are high in sodium." High sodium intake increases fluid retention, which can worsen heart failure symptoms. Furosemide is often prescribed to manage fluid overload, and sodium-rich foods would counteract its effects. A low-sodium diet is recommended.
D. “Taking furosemide can cause your potassium levels to be high." Furosemide increases the excretion of potassium through the kidneys, often leading to hypokalemia. Low potassium levels can result in muscle weakness or cardiac arrhythmias.
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