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

None

Answer and Explanation

The Correct Answer is B

A. Applying suction only during catheter removal is correct because continuous suction while inserting the catheter can cause tissue trauma and hypoxia. Intermittent suctioning during withdrawal prevents damage to the tracheal mucosa.

B. Suctioning for 30 seconds exceeds the recommended time limit, which is typically 10–15 seconds per pass for adults. Prolonged suctioning can cause hypoxia, bradycardia, and tissue trauma, making it unsafe for the client.

C. Preoxygenating with 100% oxygen before suctioning helps prevent hypoxia during the procedure. This is a standard safety measure to maintain adequate oxygen saturation levels.

D. Auscultating breath sounds before and after suctioning allows assessment of airway clearance and lung status. This step ensures that secretions have been effectively removed and helps identify any complications early.

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Correct Answer is C

Explanation

A. Give a dose of alendronate is incorrect. Alendronate is a medication used to treat osteoporosis, and it does not address low potassium levels. In this case, the focus should be on correcting the potassium imbalance.

B. Administer furosemide is incorrect. Furosemide is a diuretic that can cause further loss of potassium. In a client with low potassium levels (hypokalemia., administering furosemide could worsen the condition and lead to life-threatening complications.

C. Apply a cardiac monitor is correct. Hypokalemia (potassium level of 2.9 mEq/L) can cause significant cardiac arrhythmias, including ventricular tachycardia or fibrillation. Applying a cardiac monitor is essential for monitoring the client’s heart rhythm and detecting any abnormalities related to the low potassium level.

D. Monitor for Chvostek's sign is incorrect. Chvostek's sign is indicative of hypocalcemia, not hypokalemia. While both hypocalcemia and hypokalemia can cause neuromuscular excitability, monitoring for Chvostek’s sign is not a priority in the management of hypokalemia.

A. Tonic-clonic seizures B. Paresthesias C. Disorientation D. Sleep apnea

Correct Answer is C

Explanation

A. Tonic-clonic seizures: This is not typically expected following electroconvulsive therapy (ECT). ECT can induce a brief seizure during the procedure, but the nurse would not expect tonic-clonic seizures afterward as a direct result.

B. Paresthesias: Paresthesias (tingling or numbness) are not commonly associated with ECT. The procedure primarily affects the brain, and while some neurological symptoms may occur temporarily, paresthesias are not expected findings.

C. Disorientation: This is correct. It is common for clients to experience disorientation and confusion immediately following ECT, as it can affect memory and cognition temporarily. This typically resolves within a short period of time (minutes to hours) following the procedure.

D. Sleep apnea: Sleep apnea is not a direct or common effect of ECT. While anesthesia used during the procedure may cause some temporary respiratory changes, sleep apnea would not be expected as a typical post-procedure finding.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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