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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While the provider may need to countersign the prescription, this does not affect the accuracy of the order at the time of receiving it.
B. Verifying the medication name along with its intended purpose helps ensure clarity and reduces the risk of medication errors, especially during telephone orders where miscommunication is more likely.
C. Verbalizing "B-I-D" rather than "twice per day" could cause confusion; clear language is essential, and "twice per day" is more understandable.
D. Using the generic name rather than the trade name is recommended to avoid confusion with similar brand names.
Correct Answer is D
Explanation
A. Setting specific times for low-priority tasks may not be the most efficient use of time, as client needs can change throughout the shift.
B. Performing complicated tasks independently may not be safe, as it is essential to collaborate with other healthcare team members when necessary for patient safety.
C. Postponing checking for new prescriptions until medications are due could lead to delays in care and negatively impact client outcomes; it's important to check for updates promptly.
D. Clustering care activities for each client promotes efficiency, minimizes interruptions, and helps ensure that all care needs are met in a timely manner.
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