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 D

Explanation

A. Establishing the priorities of client care is part of the planning phase, not the implementation phase.
B. Comparing laboratory values is an assessment activity that occurs before planning and implementing care.
C. Asking the client about pain is an assessment activity used to gather information rather than an implementation task.
D. Reinforcing teaching about the client's diagnosis is an action that occurs during the implementation phase, as it involves executing the care plan and providing direct client education.

A. Abdominal CT scan with contrast. B. Esophagogastroduodenoscopy. C. Insertion of an NG tube to low intermittent suction. D. Administration of 1 unit of fresh frozen plasma.

Correct Answer is C

Explanation

A. An abdominal CT scan with contrast typically requires specific informed consent due to the use of contrast material and potential risks associated with it.
B. An esophagogastroduodenoscopy is an invasive procedure that necessitates special informed consent due to its risks and potential complications.
C. The insertion of an NG tube to low intermittent suction is considered a routine procedure that is generally included under the client's general consent for treatment.
D. The administration of fresh frozen plasma involves specific risks and usually requires informed consent because of the implications of blood product administration.

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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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Explanation

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Correct Answer is C

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