56. The practical nurse (PN) is caring for a client who has a tracheostomy tube. After donning sterile gloves, in which sequence should the PN should implement these interventions? (Arrange from the first action on top to last on the bottom.)
Insert sterile suction catheter in tracheostomy tube.
Hyperoxygenate with a bag valve mask (BVM) using a nondominant hand.
Activate suction by covering the catheter opening.
Withdraw and rotate the catheter while suction is applied.
The Correct Answer is B, A, C, D
The correct sequence for the interventions when caring for a client with a tracheostomy tube, after donning sterile gloves, is as follows:
Hyperoxygenate with a bag valve mask (BVM) using a nondominant hand. Insert sterile suction catheter in tracheostomy tube.
Activate suction by covering the catheter opening. Withdraw and rotate the catheter while suction is applied.
The first step is to hyperoxygenate the client using a bag valve mask (BVM) with the nondominant hand. This helps to ensure that the client receives adequate oxygenation during the suctioning procedure.
Next, the sterile suction catheter is inserted into the tracheostomy tube. The catheter is carefully advanced until resistance is met, ensuring it does not force its way in.
After the catheter is inserted, the suction is activated by covering the catheter opening. This creates negative pressure and allows for the removal of secretions.
Finally, the catheter is withdrawn and rotated while suction is applied. This helps to thoroughly suction the secretions from the tracheostomy tube.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
In cases of suspected child abuse, inconsistencies or discrepancies between the child's account of the injury and the caregiver's version are concerning. It raises questions about the credibility of the explanation provided by the caregiver and suggests a possible attempt to conceal the true cause of the injury. Such discrepancies may indicate that the injury was intentionally inflicted or that the child is being coerced or influenced to provide a false account.
While the other assessment findings may raise some level of concern, they are not as significant as the discrepancy between the child's and mother's versions of the injury:
A. "The mother refuses to answer questions about family history." While this behavior may raise some suspicion or cause for further investigation, it alone does not conclusively indicate child abuse. It may be related to other factors such as privacy concerns or cultural differences.
B. "The child has several abrasions on the chest and legs." While the presence of abrasions can be concerning, they alone do not provide sufficient evidence of child abuse. Children are prone to injuries and can obtain abrasions during normal play and activities.
C. "The child looks at the floor when answering the nurse's questions." This behavior may suggest shyness, anxiety, or discomfort, but it is not a definitive indicator of child abuse. Some children may exhibit such behaviors due to their personality or other factors unrelated to abuse. It is important to consider the child's overall behavior and communication patterns in conjunction with other assessment findings.
Correct Answer is B
Explanation
This is the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus. Consecutive evening serum glucose greater than 260 mg/dL indicates hyperglycemia, which means that the client's blood sugar is too high and not well controlled by the insulin dose. The PN should report this finding to the healthcare provider and expect a possible adjustment in the insulin regimen.
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