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. 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.

A. Place the client in a seclusion room. B. Engage the client in a repetitive activity as a distraction. C. Administer PRN haloperidol IM to the client. D. Apply wrist restraints to the client.

Correct Answer is B

Explanation

A. Seclusion is a highly restrictive intervention and is not the first action for managing agitation in dementia clients.
B. Engaging the client in a repetitive activity as a distraction is the least restrictive intervention and can help calm the client by redirecting their attention. Non-pharmacological and less restrictive approaches are preferred as initial responses to manage agitation in dementia clients.
C. Administering PRN haloperidol IM is a pharmacological intervention and should be reserved for situations where less restrictive measures have failed.
D. Applying wrist restraints is a restrictive intervention that can increase agitation and is not appropriate as a first-line approach.

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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?

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