A newly licensed nurse is caring for a client who requires tracheal suctioning, which is a procedure the nurse has not performed in practice. Which of the following actions should the nurse take?
Ask an experienced nurse to assist with the procedure.
Refuse to take the assignment.
Identify that the task is in the scope of RN practice and perform the suctioning.
Delegate the task to assistive personnel.
The Correct Answer is A
Choice A reason: Asking an experienced nurse to assist ensures the procedure is performed safely while allowing the newly licensed nurse to gain competence. Tracheal suctioning requires sterile technique and skill to avoid complications like hypoxia or trauma. This approach supports patient safety and professional development, aligning with nursing standards.
Choice B reason: Refusing the assignment is inappropriate, as tracheal suctioning is within an RN’s scope of practice. Refusal avoids responsibility without addressing the client’s needs or the nurse’s professional growth. Seeking assistance ensures safe care while building skills, making this choice less effective and unprofessional.
Choice C reason: Performing tracheal suctioning without prior experience risks patient harm, as it requires precise technique to prevent complications like mucosal damage or infection. Without guidance, errors are more likely. Seeking supervision ensures safety and competence, making this choice unsafe and inappropriate for a novice nurse.
Choice D reason: Delegating tracheal suctioning to assistive personnel is inappropriate, as it is a sterile procedure requiring RN-level skills and judgment. Assistive personnel are not trained for invasive procedures like suctioning, which risks complications. This choice violates delegation principles and compromises patient safety, making it incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Red meat is high in saturated fats and sodium, which can elevate blood pressure, worsening hypertension. It is not recommended for a heart-healthy diet, as it increases cardiovascular strain. The nurse should suggest leaner proteins instead, making this an incorrect dietary choice.
Choice B reason: Cheese is often high in sodium and saturated fat, contributing to increased blood pressure and cardiovascular risk in hypertension. Low-sodium alternatives are preferred, but cheese is generally discouraged, making this an inappropriate food to recommend for this client’s diet.
Choice C reason: Canned black beans are high in sodium, which exacerbates hypertension by promoting fluid retention and vascular strain. Rinsing reduces sodium, but fresh or low-sodium options are better. This choice is less ideal than fresh produce, making it incorrect for hypertension management.
Choice D reason: Fresh spinach is rich in potassium, magnesium, and fiber, which help lower blood pressure by counteracting sodium and relaxing blood vessels. It aligns with the DASH diet, an evidence-based approach for hypertension, making it the best food to recommend for this client’s condition.
Correct Answer is B
Explanation
Choice A reason: An HbA1c of 7.2% in type 1 diabetes indicates suboptimal control but is not an acute emergency. This client requires follow-up but is stable compared to life-threatening conditions, so they are not require immediate assessment, making this incorrect for prioritization.
Choice B reason: New-onset tachypnea in a hip fracture client suggests a life-threatening issue like pulmonary embolism, a common complication due to immobility. This requires immediate assessment to ensure airway and circulatory stability, aligning with ABC priorities, making it the correct first action for the nurse to take.
Choice C reason: Sinus arrhythmia is typically benign, especially with cardiac monitoring in place. It does not indicate an immediate threat compared to respiratory distress, so this client can be assessed later, making this incorrect for first priority assessment.
Choice D reason: Chest pain in a hypertensive client is concerning for cardiac issues, but tachypnea in a hip fracture suggests a more acute, potentially fatal condition like pulmonary embolism. Respiratory distress takes precedence, so this is incorrect for immediate assessment.
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