A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?
Waits for 2 min between suctions
Applies suction for 15 seconds
Encourages the client to cough during suctioning
Inserts the catheter without applying suction
None
None
The Correct Answer is C
A. Waiting for 2 minutes between suctions is a standard practice to prevent damage to the trachea and to allow the client to recover from the suctioning process. This action is also appropriate and does not require intervention.
B. Suction is typically applied for 10-15 seconds while withdrawing the catheter to prevent hypoxia and trauma to the airway.
C. Encouraging a client to cough during suctioning is generally acceptable because coughing helps expel secretions from the airway.However, the nurse should ensure that the client does not cough too forcefully, as this could lead to trauma or discomfort.
D. The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Flumazenil is a selective antagonist for the benzodiazepine receptor and is used as an antidote for benzodiazepine toxicity. It competitively inhibits the effects of benzodiazepines by binding to the same receptor sites in the central nervous system. Flumazenil can rapidly reverse the sedative and respiratory-depressant effects of benzodiazepine overdose, making it the appropriate choice in this scenario.
Choice A rationale:
Atropine is an anticholinergic medication that is used to treat bradycardia and certain types of heart block. It has no specific antidote effects for benzodiazepine toxicity and would not be the appropriate choice in this situation.
Choice C rationale:
Activated charcoal is used in the management of certain types of poisonings by adsorbing the toxic substance in the gastrointestinal tract, preventing its absorption into the bloodstream. However, it is not effective for benzodiazepine toxicity, which primarily affects the central nervous system and not the gastrointestinal tract.
Choice D rationale:
Naloxone is an opioid receptor antagonist used to reverse opioid overdose. It has no specific effects on benzodiazepine toxicity and would not be the appropriate choice in this case.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
Explanation
A. Hypoglycemia might be a concern if the baby had risk factors like maternal diabetes, but this information is not provided.
B. Tachycardia is not mentioned as a concern in the scenario, and the heart rate is within normal limits for a newborn
C. Bronchopulmonary Dysplasia (BPD): The newborn's respiratory rate is increasing over time, along with the presence of grunting and retractions. These are signs of respiratory distress. Bronchopulmonary dysplasia (BPD) is a chronic lung disease that primarily affects premature infants who require mechanical ventilation and oxygen therapy for an extended period. The symptoms align with the respiratory distress and could suggest a risk for BPD.
D. Transient Tachypnea of the Newborn (TTN): The newborn's respiratory rate is increasing over time, along with grunting and retractions. These signs are consistent with transient tachypnea of the newborn, which is a self-limiting condition characterized by rapid breathing shortly after birth. It is more common in infants born via cesarean delivery and may result from delayed clearance of lung fluid.
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