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. Hypocalcemia: Hypocalcemia, or low levels of calcium in the blood, is not typically associated with an increased risk of urolithiasis. In fact, hypercalcemia, or high levels of calcium, is more commonly linked to the formation of calcium-based kidney stones.
B. Diuretic use: Diuretic medications can increase urine production and may contribute to dehydration, which can predispose individuals to the formation of kidney stones. However, diuretic use alone is not as significant a risk factor as other factors like dehydration or specific dietary habits.
C. Family history: Family history of urolithiasis is a significant risk factor for developing kidney stones. Genetic factors can influence the likelihood of stone formation, and individuals with a family history of kidney stones are at a higher risk of experiencing them themselves.
D. BMI less than 25: Obesity and higher BMI (body mass index) are associated with an increased risk of urolithiasis. Excess body weight can lead to metabolic changes that promote the formation of kidney stones. Therefore, having a BMI less than 25 is less likely to be a risk factor compared to having a higher BMI.
Correct Answer is B
Explanation
A. Fresh frozen plasma: Fresh frozen plasma contains clotting factors, including factor VIII, but it is not the primary treatment for hemophilia A. While it can be used in emergency situations to temporarily increase clotting factor levels, it is not typically administered prophylactically before dental procedures.
B. Recombinant factor VIII: This is the correct answer. Recombinant factor VIII is the treatment of choice for individuals with hemophilia A. It is administered to replace the deficient factor VIII in the blood, thereby promoting clot formation and preventing excessive bleeding during surgical procedures such as wisdom teeth extractions.
C. Packed red blood cells (RBCs): Packed red blood cells are not typically indicated for the treatment of hemophilia A. While they may be necessary if significant blood loss occurs during the procedure, the primary treatment is replacement of the deficient clotting factor.
D. Prophylactic antibiotics: Prophylactic antibiotics may be prescribed to prevent infection following dental procedures, especially in individuals with bleeding disorders who are at increased risk of infection due to compromised immune function. However, the primary treatment for hemophilia A prior to dental procedures is replacement therapy with clotting factor concentrates like recombinant factor VIII.
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