A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene?
Applies suction during catheter removal
Suctions for 30 seconds
Preoxygenates with 100% oxygen
Auscultates breath sounds
The Correct Answer is A
A. Applies suction during catheter removal: This is correct. Suction should only be applied when the catheter is being inserted into the tracheostomy, not when it is being removed. Applying suction during removal can cause trauma to the airway and disrupt the patient's airway integrity.
B. Suctions for 30 seconds: Suctioning for 30 seconds is generally within the recommended limit for suctioning. Prolonged suctioning can lead to hypoxia and other complications, but 30 seconds is a safe duration for most patients.
C. Preoxygenates with 100% oxygen: This is correct practice. Preoxygenating the patient before suctioning is important to avoid hypoxia, especially in patients with respiratory concerns.
D. Auscultates breath sounds: This is good practice. Auscultating breath sounds before and after suctioning helps assess the patient's respiratory status and can guide the nurse in evaluating the need for suctioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Allow the antiseptic to dry before puncturing.: This is correct. It is important to allow the antiseptic (such as alcohol) to dry before puncturing the skin. If the antiseptic is not allowed to dry, it can cause hemolysis of the blood sample and lead to inaccurate glucose readings.
B. Apply sterile gloves.: This is incorrect. While gloves should be worn to maintain hygiene and safety, non-sterile gloves are sufficient for a capillary blood glucose test. Sterile gloves are not necessary unless the procedure requires aseptic technique.
C. Hold the lancet at a 45° angle.: This is incorrect. The lancet should be held at a 90° angle to the skin to ensure a proper and clean puncture.
D. Massage the client's finger away from the puncture site.: This is incorrect. The finger should not be massaged before or after the puncture site because it can cause tissue damage and lead to inaccurate blood samples due to the mixing of interstitial fluid with the blood sample.
Correct Answer is D
Explanation
A. Stating that palliative care is only for clients with a terminal illness is incorrect. Palliative care is designed for clients with serious, chronic, or life-threatening illnesses and focuses on symptom management and quality of life, regardless of prognosis.
B. Limiting palliative care to those with 6 months or less to live is incorrect. This definition applies to hospice care, not palliative care. Palliative care can be provided alongside curative treatments at any stage of illness.
C. Including restriction of nutritional support is incorrect. Palliative care emphasizes comfort and symptom relief, including providing adequate nutrition and hydration as appropriate for the client’s needs and wishes.
D. Enhancing quality of life by promoting comfort is correct. Palliative care aims to relieve symptoms such as pain, nausea, and fatigue while supporting the client’s emotional, psychological, and spiritual well-being.
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