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Finally, the catheter is withdrawn and rotated while suction is applied.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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client's complaint of a leg cramp suggests the possibility of a muscle cramp or spasm, which is a common occurrence during labor. Extending the leg and flexing the foot helps stretch and relax the affected muscle, which can alleviate the cramp. This intervention helps relieve the muscle spasm and promotes increased blood circulation to the area, potentially reducing the intensity and duration of the cramp.
A. Elevating the leg above the heart is not necessary for relieving a leg cramp. It may be helpful in certain situations, such as in the case of venous insufficiency or swelling, but it is not the First-line intervention for a leg cramp.
B. Massaging the calf and foot can be beneficial in relieving a leg cramp. However, the initial action should be to extend the leg and flex the foot to actively stretch the affected muscle. If the cramp persists or if additional comfort measures are needed, then the PN may consider massaging the calf and foot.
D. Checking the pedal pulse in the affected leg is not directly related to relieving a leg cramp. It may be a relevant assessment in certain situations, such as suspected circulatory compromise or deep vein thrombosis, but it is not the primary intervention for a leg cramp.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Based on the laboratory data, the client has:
Option 1: Pre-diabetes
Option 2: Impaired glucose tolerance
The client's fasting blood glucose level of 122 mg/dL (6.8 mmol/L) falls within the range of 100 to 125 mg/dL (5.56 to 6.9 mmol/L), indicating impaired glucose tolerance. This suggests that the client's blood sugar levels are higher than normal but not high enough to be classified as diabetes mellitus.
Impaired glucose tolerance is considered a precursor to diabetes and indicates an increased risk of developing diabetes in the future. It is important for the practical nurse to educate the client about lifestyle modifications to manage blood sugar levels and prevent the progression to diabetes.
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