A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Insert the catheter until resistance is felt

Withdraw the catheter 1 to 2 cm (0.4 to 0.8 inch)

Rotate the catheter while suctioning

Lubricate the catheter with sterile saline.

Answer and Explanation

The Correct Answer is D,A,B,C

Rationale:

A. Insert the catheter until resistance is felt: The catheter should be gently advanced into the tracheostomy tube until resistance is met, which typically indicates reaching the carina.

B. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 inch): Slight withdrawal prevents trauma to the carina and positions the catheter optimally for effective suctioning.

C. Rotate the catheter while suctioning: Rotating the catheter as suction is applied allows for even clearing of secretions along the tracheal walls and helps prevent localized tissue damage.

D. Lubricate the catheter with sterile saline: Lubrication ensures smooth insertion and reduces trauma to the tracheal mucosa. This is the first action after applying sterile gloves.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Rationale:

Prenatal anemia: Anemia may impair immune function and tissue oxygenation, making the postpartum client more vulnerable to infections such as endometritis, especially after cesarean delivery.
Polyhydramnios: Excessive amniotic fluid stretches the uterus beyond normal capacity, which can impair uterine contractility postpartum, increasing the risk of uterine atony and resulting in subinvolution or hemorrhage.
High parity: Multiple previous pregnancies lead to uterine muscle fatigue, reducing tone and contractility, which predisposes the uterus to poor involution and increases the risk of uterine atony.

Prolonged rupture of membranes: A rupture lasting more than 18 hours increases the risk of ascending bacterial infection and is a significant risk factor for postpartum endometritis or chorioamnionitis.

A. Maintain bed elevation at 20° B. Check for gastric residual every 12 hr. C. Flush the tubing with 30 mL of water every 4 hr. D. Place enough formula in the container to last 18 hr.

Correct Answer is C

Explanation

Rationale:

A. Maintain bed elevation at 20°: To reduce the risk of aspiration, the head of the bed should be elevated to at least 30°–45° during and after enteral feedings. A 20° elevation is insufficient to prevent gastric reflux and aspiration.

B. Check for gastric residual every 12 hr: Gastric residuals should generally be checked every 4–6 hours for clients receiving continuous enteral feedings. Waiting 12 hours increases the risk of feeding intolerance or aspiration from undetected residual accumulation.

C. Flush the tubing with 30 mL of water every 4 hr: Routine flushing helps prevent tube occlusion and maintains patency. It also ensures that the client receives adequate hydration, especially with continuous feeding systems.

D. Place enough formula in the container to last 18 hr: Formula in an open system should not hang longer than 4 hours due to the risk of bacterial contamination. Adding 18 hours’ worth increases the chance of microbial growth and infection.

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A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open system. Which of the following Interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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