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)
Insert the catheter until resistance is felt
Lubricate the catheter with sterile saline
Rotate the catheter while suctioning
Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in)
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 At this point, it should be slightly withdrawn (1–2 cm) to avoid mucosal damage.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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sacrum: The sacrum is typically assessed for pressure injuries but is not the most reliable site for detecting cyanosis in clients with dark skin because of variable pigmentation.
B. Shoulders: The shoulders have significant pigmentation and are not ideal for assessing cyanosis in dark-skinned clients due to difficulty distinguishing color changes.
C. Area of trauma: Trauma sites may show redness or bruising unrelated to cyanosis, making them unreliable for assessing oxygenation status.
D. Palms of the hands: The palms have less melanin and are lighter in color, making them a better site to observe for cyanosis in clients with dark skin due to clearer visualization of bluish discoloration.
Correct Answer is A
Explanation
A. A client who is ambulatory and receiving oxygen: Ambulatory clients who can move with minimal assistance should be evacuated first, especially if they are near the fire. Their mobility allows for quick removal from danger, and oxygen equipment can be disconnected quickly if needed.
B. A client who uses a wheelchair and is confused: This client will require assistance due to limited mobility and altered cognition. They are not the highest priority for initial evacuation unless directly threatened by fire.
C. A client who is bedridden and wears a hearing aid: This client needs considerable assistance to evacuate and may have communication limitations due to hearing impairment, making evacuation more complex and slower.
D. A client who has a fracture and is in balance suspension traction: This client is immobile and dependent on staff for movement, requiring more time and coordination. They are typically evacuated later unless in immediate danger.
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