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 B
Explanation
A. Anorexia: This is not a common or serious adverse effect of heparin. It is not usually a priority for reporting to the provider.
B. Epistaxis: This is correct. Heparin is an anticoagulant, and one of the major risks associated with its use is bleeding. Epistaxis (nosebleeds) is a common sign of bleeding that could be a result of heparin therapy, and it should be reported to the provider promptly.
C. Bradycardia: Bradycardia is not a common adverse effect of heparin. Heparin primarily affects clotting mechanisms, not heart rate.
D. Weight gain: Weight gain is not a typical adverse effect of heparin. If the weight gain is significant or linked to fluid retention, it may need to be assessed, but it is not a typical reaction to heparin.
Correct Answer is D
Explanation
A. "My child still wets the bed at least two times per week." While this is a concern, bedwetting can be a normal developmental behavior for children at this age and does not necessarily indicate a problem unless it persists beyond the typical age range.
B. "I have a difficult time getting my child to eat green vegetables." This is a common concern for parents of young children and typically does not warrant immediate attention, although it may require guidance on healthy eating habits.
C. "My child continually asks me the same questions." Repetition of questions is a normal part of cognitive development in young children and does not indicate an issue by itself.
D. "I have noticed that my child is withdrawn since we switched day care providers." This is the priority concern. Withdrawal or behavioral changes, particularly after a significant event like a change in day care, can indicate stress, anxiety, or possible emotional issues, and the nurse should address this promptly to ensure the child's well-being.
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