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128. 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 on the right. placing them in the selected order of performance, use all the steps.) (ORDERED RESPONSE)

A.

Insert the catheter until resistance is felt

B.

Lubricate the catheter with sterile saline

C.

Rotate the catheter while suctioning

D.

Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in)

Answer and Explanation

The Correct Answer is B,A,D,C

After donning sterile gloves, the nurse must first lubricate the catheter with sterile saline to reduce friction during insertion. The catheter is then inserted gently until resistance is felt, indicating it has reached the tracheal wall. At this point, it should be slightly withdrawn (1–2 cm) to avoid mucosal damage. Suction is then applied while rotating the catheter to evenly clear secretions from the airway.


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Related Questions

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale for Correct Answer:

  • Falls due to genitourinary assessment findings: The client reports urinary frequency and urgency, and the urinalysis reveals positive nitrites and leukocyte esterase, indicating a urinary tract infection (UTI). These symptoms can increase nighttime bathroom trips and rushing to void, both of which raise fall risk, especially in hospitalized or postpartum clients.

Rationale for Incorrect Choices:

  • Impaired nutrition due to genitourinary assessment findings: There are no signs of inadequate intake, weight loss, or gastrointestinal symptoms. The client has a normal appetite and no vomiting or diarrhea, and the UTI is unrelated to nutritional deficits.
  • Pressure injuries due to blood pressure findings: The client’s blood pressure is within acceptable limits for adults and does not suggest hypoperfusion or immobility-related risk. Additionally, no skin issues or limited mobility were reported.
  • Falls due to mobility findings: While falls are possible with impaired mobility, the nurse noted that the client has a steady gait, indicating that mobility is intact and not contributing to fall risk.

Correct Answer is D

Explanation

A. Abdominal aortic aneurysm: While this condition is serious, it does not directly affect the safety of applying localized heat therapy to a distal site like the foot, unless systemic complications are present.
B. Osteoarthritis: Heat therapy is often beneficial in osteoarthritis, as it helps reduce joint stiffness and improve circulation to the affected area, making it a common and safe intervention.
C. Phlebitis: Warm compresses are sometimes used in phlebitis to reduce inflammation and promote comfort, provided there are no signs of infection or severe vascular compromise.
D. Peripheral neuropathy: Clients with peripheral neuropathy have impaired sensation and may not feel excessive heat, increasing the risk of burns or tissue injury. This makes heat therapy unsafe for these individuals.

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