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. 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.

A. Replace nonperishable food items annually. B. Have a backup supply of nonprescription medications. C. Stock 2 liters of water per person per day. D. Gather enough supplies to last for 2 weeks.

Correct Answer is B

Explanation

A. Replace nonperishable food items annually: While rotating nonperishable food supplies is important, many nonperishable items have longer shelf lives, and replacement frequency depends on expiration dates. This is not the most essential point to include.

B. Have a backup supply of nonprescription medications: This is crucial for older adults who often rely on medications such as pain relievers, antacids, or allergy medications. In a disaster, access to pharmacies may be limited, making backup supplies essential for maintaining health.

C. Stock 2 liters of water per person per day: The recommended amount is generally at least 3.8 liters (1 gallon) of water per person per day for drinking and sanitation, not 2 liters.

D. Gather enough supplies to last for 2 weeks: While two weeks is ideal in some emergency plans, the standard recommendation by organizations such as FEMA is at least 3 days of supplies. Therefore, this advice may not be the most practical or commonly endorsed in a general teaching session.

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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 B

Explanation

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