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
None
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bleeding: While haloperidol can rarely cause agranulocytosis, which may lead to bleeding, it is not a common adverse effect associated with the medication. However, clients taking antipsychotic medications like haloperidol should be monitored for any signs of bleeding, such as petechiae or bruising.
B. Cataracts: Haloperidol is not typically associated with the development of cataracts. However, long-term use of certain antipsychotic medications, including haloperidol, may increase the risk of developing metabolic side effects such as weight gain and dyslipidemia, which could indirectly contribute to the risk of cataract formation.
C. Dysrhythmias: This is the correct answer. Haloperidol has the potential to prolong the QT interval, leading to a type of dysrhythmia known as torsade’s de pointes. Therefore, clients taking haloperidol should be monitored for signs of QT prolongation, such as palpitations, syncope, or sudden cardiac arrest.
D. Pancreatitis: While rare, haloperidol has been associated with pancreatitis as a potential adverse effect. However, dysrhythmias are a more common and immediate concern, especially with acute administration or in clients with predisposing factors for QT prolongation, such as electrolyte imbalances or concurrent use of other medications known to prolong the QT interval.
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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