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A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Lubricate the suction catheter tip with sterile saline

Suction two to three times with a 50-second pause between passes

Hyperventilate the client on 100% oxygen prior to suctioning

Perform chest physiotherapy prior to suctioning

None

Answer and Explanation

The Correct Answer is C

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

A. Lubricate the catheter with water-soluble gel.
Lubrication is important to reduce urethral trauma, but this is not the first step once the sterile field is prepared. It comes after draping and cleansing, just before catheter insertion.

B. Position the sterile drape leaving the perineum exposed.
This is the first action after donning sterile gloves and preparing the field. Draping maintains a sterile environment and provides access to the insertion site. Ensuring sterility from the beginning is critical for preventing catheter-associated infections.

C. Cleanse the client’s meatus with antiseptic solution.
Cleansing the meatus is done after draping to reduce the risk of introducing microorganisms during catheter insertion. Although essential, it is not the very first step once the sterile procedure begins.

D. Attach a prefilled syringe to the catheter inflation hub.
The balloon should not be prepared or inflated until after the catheter has been inserted and urine return is observed. Attaching the syringe too early may risk accidental inflation outside the bladder.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Secure the restraints to the lowest bar of the side rail:
This is incorrect. Restraints should not be secured to the side rails of the bed because the client may injure themselves by attempting to climb over the side rail or if the bed adjusts, it can cause excessive pressure on the restrained limb.
B. Ensure four fingers under the restraints to prevent constriction:
This is incorrect. The nurse should be able to slide two fingers under the restraint to ensure it is not too tight, rather than four fingers. Restraining too loosely may allow the client to slip out, while restraining too tightly can cause tissue damage or compromise circulation.
C. Secure the restraints using a quick-release tie:
This is the correct action. Restraints should always have quick-release ties to allow for quick removal in case of an emergency or if the client needs to be repositioned or assisted. Velcro or buckle restraints with quick-release mechanisms are commonly used to ensure easy removal.
D. Anticipate removing the restraints every 4 hr:
While it's essential to regularly assess the need for continued restraint use and ensure restraints are not overly restrictive, there's no set time interval for removing restraints. Restraints should be removed as soon as they are no longer necessary to ensure the client's safety and comfort.

A. "I will wear gloves when removing food from the freezer" B. "I will take my medications at the first sign of an attack" C. "I will try to anticipate and avoid stressful situations when possible" D. "I will complete the smoking cessation program I started"

Correct Answer is B

Explanation

A. "I will wear gloves when removing food from the freezer": This statement demonstrates understanding of the need to protect the hands from cold exposure, which can trigger Raynaud's disease symptoms. Wearing gloves when handling cold objects, such as food from the freezer, helps minimize the risk of a vasospastic episode.
B. "I will take my medications at the first sign of an attack": This statement indicates a misunderstanding of the appropriate use of medications for Raynaud's disease. While medications such as calcium channel blockers may be prescribed to prevent or reduce the frequency and severity of attacks, they are typically taken regularly as part of ongoing management rather than at the first sign of symptoms. This client may need additional education on the proper use of medications for Raynaud's disease.
C. "I will try to anticipate and avoid stressful situations when possible": Stress can exacerbate symptoms of Raynaud's disease by triggering vasospasm, so anticipating and avoiding stressful situations is a proactive strategy to help prevent attacks. This statement reflects an understanding of the importance of stress management in managing the condition.
D. "I will complete the smoking cessation program I started": Smoking is a significant risk factor for Raynaud's disease and can worsen symptoms by constricting blood vessels. Committing to a smoking cessation program demonstrates the client's recognition of the importance of lifestyle modifications in managing the condition.

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A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

Nursing Test Bank

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A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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