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 A
Explanation
Choice A reason: Smoked salmon is high in tyramine, which phenelzine, an MAOI, prevents from being metabolized. This risks hypertensive crisis due to norepinephrine release, potentially causing stroke or cardiovascular complications. Avoiding tyramine-rich foods is critical for safety in clients on MAOI therapy.
Choice B reason: Cottage cheese is low in tyramine, safe for phenelzine users. Unlike aged cheeses, fresh dairy poses minimal risk of hypertensive crisis, as it lacks significant tyramine content. MAOIs require avoiding high-tyramine foods, making cottage cheese an acceptable dietary choice for these clients.
Choice C reason: Grapefruit affects CYP450 enzymes, interacting with some drugs, but is not contraindicated with phenelzine. It lacks significant tyramine, so it does not trigger hypertensive crises. Avoidance is unnecessary, as it does not impact MAOI metabolism or related cardiovascular risks.
Choice D reason: Fresh apples are low in tyramine and safe for phenelzine users. MAOIs require avoiding tyramine-rich foods like aged meats, but fresh fruits do not cause hypertensive crises, as they lack amino acids interacting with MAOI metabolism, making them safe for consumption.
Correct Answer is B
Explanation
Choice A reason: Performing postural drainage immediately after meals risks aspiration and discomfort due to gastric contents shifting during positioning. It should be done 1-2 hours after meals to ensure safety and efficacy in clearing mucus from the lungs, making this timing inappropriate for cystic fibrosis management.
Choice B reason: Performing postural drainage twice daily is recommended for cystic fibrosis to mobilize thick mucus from the lungs, improving airway clearance and reducing infection risk. This frequency balances effectiveness with patient tolerance, aligning with evidence-based guidelines for managing chronic respiratory conditions, making it the correct action.
Choice C reason: Using a percussion vest is an alternative to manual postural drainage but is not specified as the only method. Manual techniques are effective and standard unless a vest is prescribed. This choice assumes equipment availability, which may not apply, making it less universally appropriate than scheduled manual drainage.
Choice D reason: Positioning the child flat during postural drainage is incorrect, as specific angled positions (e.g., head-down) are needed to target lung segments and promote mucus drainage by gravity. Flat positioning reduces effectiveness and may not clear airways adequately, making this an inappropriate technique for cystic fibrosis.
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