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.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Referring to a mental health clinic addresses potential emotional distress but not the adolescent’s primary concern of affordability. Pregnancy increases psychological stress, but financial barriers to prenatal care are critical. This action fails to ensure access to medical resources, essential for maternal and fetal health in adolescent pregnancy.
Choice B reason: Contacting the adolescent’s parent risks breaching confidentiality, depending on legal guidelines, and does not address financial concerns directly. Family dynamics may complicate support, and without consent, this action could increase stress, failing to provide immediate healthcare access critical for a healthy pregnancy outcome.
Choice C reason: Assisting with Medicaid application directly addresses financial concerns, ensuring access to prenatal care, delivery, and postpartum support. Medicaid reduces risks like preterm birth by covering medical and nutritional needs, critical for adolescent mothers with limited resources, aligning with public health goals for maternal-fetal well-being.
Choice D reason: Advising adoption is premature and overlooks the adolescent’s autonomy. Adoption requires extensive counseling, not immediate recommendation. It fails to address healthcare access, critical for a healthy pregnancy. This approach dismisses financial solutions, potentially increasing stress and undermining informed decision-making in pregnancy.
Correct Answer is D
Explanation
Choice A reason: Encouraging a final hemodialysis treatment contradicts the client’s advance directives, which refuse life-sustaining treatments. Respecting autonomy is paramount, and persuading the client undermines their decision, making this action unethical and inappropriate in this end-of-life scenario.
Choice B reason: Contacting the family to discuss the decision is unnecessary unless the client is incapacitated, which is not indicated. The client’s advance directives guide care, and family input is secondary to the client’s wishes, making this action incorrect and irrelevant.
Choice C reason: Discussing treatment options with the surrogate is inappropriate, as the client is competent and has clear advance directives refusing treatment. The surrogate’s role applies only if the client cannot decide, making this action misaligned with the client’s autonomy and directives.
Choice D reason: Discussing discharge options respects the client’s refusal of treatment and advance directives, focusing on palliative care or home arrangements. This supports autonomy and aligns with end-of-life care principles, ensuring comfort and dignity, making it the correct action.
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