A registered nurse assigns the task of tracheostomy suctioning of a client to the Licensed Practical Nurse (LPN). The LPN informs the nurse that the LPN has never performed this procedure on a client. Which of the following is the most appropriate response from the registered nurse?
You are through with your theory class, so you should know.
Ask for help from a nurse who knows how to perform the procedure.
Review the procedure in the manual and act accordingly.
I will assist you in performing the procedure on the client.
The Correct Answer is D
Choice A reason: Assuming the LPN should know tracheostomy suctioning from theory dismisses the need for practical experience. Performing procedures safely requires supervised practice, as inexperience risks airway trauma or infection. This response neglects patient safety and professional mentorship, per nursing delegation standards.
Choice B reason: Asking another nurse for help is insufficient, as it does not ensure proper supervision or competency. The RN is responsible for ensuring the LPN’s ability to perform safely. This approach risks inconsistent training and patient harm, lacking structured guidance, per delegation and patient safety protocols.
Choice C reason: Reviewing the manual alone is inadequate for a hands-on procedure like tracheostomy suctioning, which requires supervised practice to ensure competence. Inexperience may lead to errors, such as hypoxia or infection. This response fails to provide direct oversight, per nursing competency and patient safety guidelines.
Choice D reason: Assisting the LPN in performing tracheostomy suctioning ensures patient safety and builds competency. The RN provides direct supervision, preventing errors like airway obstruction or infection, while mentoring the LPN. This aligns with delegation principles, ensuring effective care and professional development, per nursing practice standards.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Using a fluorescent light source may not adequately reveal Stage I pressure ulcers in dark skin, as color changes are subtle. Natural or halogen light is preferred to detect darkening or erythema. Fluorescent light can distort pigmentation, reducing accuracy, per dermatological assessment techniques.
Choice B reason: Inspecting skin only if the Braden score indicates risk may miss early Stage I ulcers, which present as non-blanchable darkening in dark skin. Routine inspection is essential, as Braden scores predict risk but do not confirm ulcers, potentially delaying intervention, per pressure injury protocols.
Choice C reason: Avoiding touching the skin during inspection is inappropriate, as palpation detects warmth, induration, or non-blanching, key for Stage I ulcers in dark skin. Tactile assessment complements visual inspection, ensuring accurate identification of early tissue damage, per comprehensive skin assessment guidelines.
Choice D reason: Looking for skin darker than surrounding areas is the best approach for Stage I pressure ulcers in dark skin, as they present as non-blanchable hyperpigmentation rather than redness. This visual change indicates early tissue damage, guiding timely intervention to prevent progression, per pressure ulcer staging standards.
Correct Answer is C
Explanation
Choice A reason: Cyanosis, a bluish skin discoloration, indicates hypoxemia in COPD due to impaired gas exchange in damaged alveoli. While concerning, it is a common chronic symptom and not immediately life-threatening unless rapidly worsening. Decreased level of consciousness signals severe hypoxia affecting cerebral oxygenation, requiring urgent reporting over stable cyanosis.
Choice B reason: Wheezing results from airway obstruction in COPD, caused by bronchoconstriction and mucus accumulation, reducing airflow. It’s a chronic symptom managed with bronchodilators. While important, it does not indicate acute decompensation like decreased consciousness, which reflects critical cerebral hypoxia and requires immediate intervention to prevent brain damage.
Choice C reason: Decreased level of consciousness indicates severe hypoxia in COPD, as low oxygen saturation impairs cerebral function. Brain cells require constant oxygen for ATP production via aerobic metabolism. Hypoxia reduces cerebral perfusion, causing confusion or unresponsiveness, signaling a life-threatening emergency. This finding warrants immediate reporting to address acute respiratory failure.
Choice D reason: Frequent coughing in COPD results from mucus production and airway irritation, a common chronic symptom. It aids in clearing secretions but does not indicate acute decompensation. Unlike decreased consciousness, which reflects severe cerebral hypoxia, coughing is less urgent and managed with expectorants or airway clearance techniques, not immediate reporting.
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