2100 hrs - Critical Incident

Exhibits

A nurse is providing discharge teaching to a client recently diagnosed with a latex allergy. Which of the following client statements indicates a need for further teaching?

Choice A rationale

As an advocate, the nurse acts to protect the patient’s rights and helps them to speak for themselves. This includes supporting the patient’s decisions, even when these decisions might not be in line with the nurse’s personal beliefs.

Choice B rationale

As a manager, the nurse coordinates activities of members of the nursing staff in delivering nursing care, and oversight ensures that care is safe, effective, and patient-centered.

Choice C rationale

As a caregiver, the nurse assists patients with meeting their physical, psychological, and developmental needs. This role involves direct patient care activities.

Choice D rationale

As an educator, the nurse works to enhance patients’ knowledge about their health and care, promoting health behaviors and self-care skills.

Choice A rationale

Lubricating the suction catheter tip with sterile saline is not recommended because it can introduce bacteria into the tracheostomy tube and cause infection.

Choice B rationale

Hyperventilating the patient on 100% oxygen prior to suctioning is not necessary and can cause complications such as oxygen toxicity.

Choice C rationale

Performing chest physiotherapy prior to suctioning is not typically done during tracheostomy care. Chest physiotherapy is a separate procedure that involves physical techniques to remove mucus from the respiratory tract.

Choice D rationale

Suctioning two to three times with a 60-second pause between passes is the correct action. This helps to remove secretions effectively without causing hypoxia.