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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Oral suction equipment is correct. During a seizure, there is a risk of aspiration due to the loss of airway control. Oral suction equipment should be readily available in the room to clear the airway if needed, especially if the client experiences a seizure with oral secretions.
B. Tongue depressor is incorrect. A tongue depressor should never be used during a seizure. Inserting a tongue depressor into the mouth can result in injury to both the client and the caregiver and should be avoided.
C. Tracheostomy tray is incorrect. While a tracheostomy tray might be necessary for clients with tracheostomies, it is not a standard requirement for clients on seizure precautions unless the client has specific respiratory concerns or requires a tracheostomy for airway management.
D. Wrist restraints is incorrect. Wrist restraints are not recommended during a seizure, as they can cause injury and impede movement. Instead, the goal is to provide a safe environment to prevent injury during a seizure.
Correct Answer is A
Explanation
A. Place a pillow under the child's head: This is correct. The nurse should place a soft object, such as a pillow or folded blanket, under the child’s head to prevent head injury during a seizure. It is important to protect the patient from harm without interfering with the seizure.
B. Turn the child onto their back: This is not advisable during a seizure. The child should remain in a safe position, preferably on their side to help maintain the airway and prevent aspiration. Turning onto their back is not a first-line intervention.
C. Place a padded tongue blade in the child's mouth: This is incorrect. A padded tongue blade should never be inserted into the mouth during a seizure, as it can cause dental or oral injury, and may lead to aspiration or choking.
D. Restrain the child's upper extremities: Restraining the child is not recommended during a seizure. The child should not be physically restrained during the event, as this could cause injury or increase the risk of aspiration. The nurse should focus on providing safety and not interfering with the natural movements during a seizure.
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