A nurse is supervising a newly licensed nurse who is suctioning a client who has a tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Waits 2 min between suction passes.

Wears clean gloves during suctioning.

Turns the pressure on the suction to 200 mm Hg.

Applies suction while inserting the catheter.

Answer and Explanation

The Correct Answer is A

A. Waiting 2 minutes between suction passes allows the client to recover and helps to prevent hypoxia, demonstrating an understanding of the suctioning procedure.
B. Wearing clean gloves during suctioning is not appropriate; sterile gloves should be used to prevent introducing pathogens into the airway.
C. The recommended suction pressure for adults is typically between 80 and 120 mm Hg; therefore, setting the suction to 200 mm Hg is too high and could cause trauma to the airway.
D. Suction should be applied only while withdrawing the catheter, not while inserting it, to minimize trauma and prevent oxygen deprivation.

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Correct Answer is B

Explanation

A. Removing gloves before leaving an isolation room is appropriate practice and helps prevent the spread of infection.
B. Filling a basin with water at 40° C (104° F) is too hot for foot care and could lead to burns or injury; water temperature for foot care should be comfortably warm, typically around 37°C (98.6°F).
C. Instructing a client to look down at their feet when being assisted to ambulate is a safety measure that can help the client maintain balance and avoid tripping.
D. Applying water-soluble lubricant to the nares of a client receiving oxygen is a standard practice to prevent dryness and does not require intervention.

A. Discuss the implications of the client's discharge with the ethics committee. B. Call the client's provider and suggest delaying discharge. C. Suggest the client consider placement in a long-term care facility. D. Recommend a referral for the client to social services.

Correct Answer is D

Explanation

A. Consulting the ethics committee is unnecessary at this stage, as there is no ethical dilemma in arranging social support services.
B. Suggesting a discharge delay is premature and may not be feasible; alternative support should be considered first.
C. Long-term care facility placement is a more permanent solution and may not align with the client’s needs or preferences.
D. Recommending a referral to social services is appropriate as social services can help arrange post-discharge support, including home health services or community resources, ensuring a safe transition home.

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A nurse is supervising a newly licensed nurse who is suctioning a client who has a tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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