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 D
Explanation
A. Acetaminophen: Acetaminophen is an effective analgesic for mild to moderate pain but may not be sufficient for managing postoperative pain after a total knee arthroplasty, where moderate to severe pain is common.
B. Ibuprofen: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID. that can be used for pain, but it may not be the best choice for moderate to severe postoperative pain, as opioids are typically more effective for this type of pain.
C. Celecoxib: Celecoxib is an NSAID, and like ibuprofen, it can be useful for managing pain, but for a postoperative pain level of 6, a stronger medication like an opioid may be more appropriate.
D. Oxycodone: Oxycodone is an opioid analgesic, and it is typically used to manage moderate to severe pain, such as the pain a patient may experience after total knee arthroplasty. It would be the most appropriate choice for a pain level of 6 on a 0–10 scale.
Correct Answer is A
Explanation
A. "It is your choice to share personal information during group therapy" is correct. The ethical principle of autonomy emphasizes respecting a client's right to make decisions about their own care, including the right to share or withhold personal information. Allowing the client to choose what to share supports their independence and decision-making ability.
B. "I will be truthful when answering questions about your treatment" promotes veracity, not autonomy. While truthfulness is important in nursing, it does not directly pertain to the principle of client autonomy.
C. "The nursing staff here will provide you with nonjudgmental care" promotes beneficence and respect for the client's dignity, but it does not directly address the principle of autonomy, which focuses on the client’s ability to make choices.
D. "I will only discuss your medical information with the health care team" supports confidentiality and privacy, not autonomy. Autonomy involves respecting a client’s decision-making, not just protecting their information.
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