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

Answer and Explanation

The Correct Answer is C

Answer: C. Hyperventilate the client on 100% oxygen prior to suctioning

Rationale:

A) Lubricate the suction catheter tip with sterile saline: Lubricating the suction catheter tip is not recommended, as it can introduce additional fluids into the airway and may contribute to complications or further secretions.

B) Suction two to three times with a 50-second pause between passes: While it is appropriate to limit suctioning passes to minimize trauma, the pause should generally be 30 seconds to allow for reoxygenation. A 50-second pause could result in hypoxia.

C) Hyperventilate the client on 100% oxygen prior to suctioning: This action is crucial as it helps to preoxygenate the client, minimizing the risk of hypoxia during the suctioning procedure. Hyperventilation with 100% oxygen helps maintain adequate oxygen levels, especially when the airway may be compromised.

D) Perform chest physiotherapy prior to suctioning: While chest physiotherapy can help mobilize secretions, it is typically done as a separate intervention and not immediately before suctioning. The priority during suctioning is to clear secretions efficiently and safely, and chest physiotherapy may not be necessary right before this procedure.

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Correct Answer is B

Explanation

A. The client who has a chest tube to water seal: A chest tube to water seal is primarily used to drain air or fluid from the pleural space. While the client with a chest tube may experience electrolyte imbalances due to fluid loss, hypokalemia is not directly associated with this type of drainage system.
B. The client who has a nasogastric (NG) tube to suction: Clients with nasogastric tubes to suction may experience hypokalemia due to the loss of gastric contents, which contain potassium. Suctioning removes gastric secretions, including potassium, from the body, leading to the risk of electrolyte imbalances such as hypokalemia.
C. The client who has an indwelling urinary catheter to gravity drainage: Gravity drainage of urine via an indwelling urinary catheter does not typically lead to significant potassium loss. While urinary catheterization may carry a risk of electrolyte imbalances over time, it is not as directly associated with hypokalemia as suctioning gastric contents.
D. The client who has a tracheostomy tube attached to humidified oxygen: Humidified oxygen delivery through a tracheostomy tube does not directly affect potassium levels. While clients receiving oxygen therapy may have other respiratory-related issues, hypokalemia is not typically a concern related to this type of therapy.

A. Fidelity B. Veracity C. Utilitarianism D. Non-maleficence

Correct Answer is D

Explanation

A. Fidelity: Fidelity refers to the duty to fulfill one's commitments and obligations. While important in nursing practice, fidelity is not directly applicable to the decision not to administer pain medication in this scenario.
B. Veracity: Veracity refers to truthfulness and honesty in communication. While it is important for the nurse to communicate honestly with the client and their family about the risks and benefits of pain management, the decision not to administer pain medication is primarily based on the principle of non-maleficence.
C. Utilitarianism: Utilitarianism is an ethical theory that emphasizes the greatest good for the greatest number of people. While pain relief may contribute to the overall well-being of the client, the decision not to administer pain medication in this scenario is more closely aligned with the principle of non-maleficence, as it focuses on avoiding harm to the individual client.
D. Non-maleficence: Non-maleficence is the ethical principle that emphasizes the duty to do no harm. In this situation, the nurse's primary concern is to avoid causing harm to the client. Administering pain medication to relieve suffering, even if it might hasten death, aligns with the principle of non-maleficence because the intent is to alleviate suffering and provide comfort to the dying client.

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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?

Nursing Test Bank

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