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.
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Related Questions
Correct Answer is C,B,A,D
Explanation
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.
Correct Answer is C
Explanation
A. "You will feel your baby moving within the next month." Fetal movement, or quickening, is typically felt between 16 and 20 weeks of gestation. At 9 weeks, it is too early for the client to detect fetal movement.
B. "Hormone shifts often cause vulvar itching." Vulvar itching is not a common or expected symptom of early pregnancy and may indicate an infection, such as a yeast infection, rather than a normal hormonal change.
C. "You should consume at least 3 liters of fluid each day." Adequate hydration is essential during pregnancy to support increased blood volume, amniotic fluid, and metabolic processes. A daily intake of about 3 liters of fluid helps prevent dehydration and constipation.
D. “Headaches are expected throughout pregnancy." While headaches can occur, especially in the first trimester due to hormonal changes, persistent or severe headaches may indicate complications like preeclampsia and should not be considered a normal, ongoing expectation.
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