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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.

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Correct Answer is C

Explanation

A. At the beginning: Examining the tympanic membrane at the beginning of the physical examination may not be ideal because it disrupts the flow of the assessment. It's more logical to start with general observations and proceed to more specific areas of assessment.
B. Before auscultating the chest and abdomen: While examining the tympanic membrane before auscultating the chest and abdomen may seem reasonable, it's not the optimal sequence. The nurse should focus on assessing major body systems before proceeding to more specific areas, such as the ears.
C. At the end: This is the correct approach. After completing the assessment of major body systems, such as the cardiovascular, respiratory, and abdominal systems, the nurse can then proceed to examine the ears, including the tympanic membrane. This sequence ensures a systematic and organized assessment.
D. Before examining the head and neck: While examining the tympanic membrane before the head and neck may seem logical due to proximity, it's more practical to conduct a comprehensive head-to-toe assessment first before focusing on specific areas like the ears.

A. pH 7.55, HCO 30 mEq/L. PaCO2 31 mm Hg B. pH 7.30, HCO 26 mEq/L. PaCO, 50 mm Hg C. pH 7.50, HCD, 20 mEq/L PaCO 32 mm Hg D. pH 7.25 HCO, 19 mEq, PaCO, 30 mm Hg

Correct Answer is D

Explanation

A. pH 7.55, HCO3 30 mEq/L, PaCO2 31 mm Hg: These values indicate respiratory alkalosis with metabolic alkalosis. The pH is elevated, indicating alkalosis. The HCO3 level is elevated, indicating metabolic alkalosis, while the PaCO2 is low, indicating respiratory alkalosis. This pattern is not typically seen in chronic kidney disease.
B. pH 7.30, HCO3 26 mEq/L, PaCO2 50 mm Hg: These values indicate metabolic acidosis with respiratory acidosis. The pH is low, indicating acidosis. The HCO3 level is slightly low, indicating metabolic acidosis, while the PaCO2 is elevated, indicating respiratory acidosis. This pattern is not typically seen in chronic kidney disease.
C. pH 7.50, HCO3 20 mEq/L, PaCO2 32 mm Hg: These values indicate metabolic alkalosis with respiratory alkalosis. The pH is elevated, indicating alkalosis. The HCO3 level is elevated, indicating metabolic alkalosis, while the PaCO2 is slightly low, indicating respiratory alkalosis. This pattern is not typically seen in chronic kidney disease.
D. pH 7.25, HCO3 19 mEq/L, PaCO2 30 mm Hg: These values indicate metabolic acidosis. The pH is low, indicating acidosis. The HCO3 level is decreased, indicating metabolic acidosis, while the PaCO2 is within the normal range. In chronic kidney disease, impaired kidney function leads to the retention of metabolic acids, resulting in metabolic acidosis. This pattern is consistent with chronic kidney disease.

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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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