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

Answer and Explanation

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D.   The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.

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Correct Answer is ["C","D","G"]

Explanation

Based on the provided information, the nurse should include the following statements in the client's teaching:

C. "Wear loose-fitting clothing": This is because the specific gravity of the urine is slightly elevated (1.022), which may indicate mild dehydration. Loose-fitting clothing can help promote comfort and ventilation, especially in cases of dehydration.

D. "Wear flat or low-heeled shoes": There is no specific indication related to the urine dipstick results, but it is generally good advice for maintaining proper foot health and preventing strain on the feet and ankles.

G. "You should avoid fried foods": There are no specific indications related to the urine dipstick results, but a healthy diet is always beneficial for overall well-being. Avoiding fried foods can be a part of a balanced diet and promote better health.

The following statements should not be included in the client's teaching based on the provided urine dipstick results:

A. "Try using an abdominal support belt": There is no indication related to the urine dipstick results that suggests the need for an abdominal support belt.

B. "Take hot showers to help relieve itching": Itching is not mentioned in the urine dipstick results, so there is no specific indication to recommend hot showers for this purpose.

E. "You can douche twice weekly": Douche is not related to urine dipstick results, and douching is generally not recommended as it can disrupt the natural balance of vaginal flora and may cause more harm than good.

F. "Eat two large meals a day": There is no indication related to the urine dipstick results that suggests a specific meal plan, and eating two large meals a day may not be suitable for everyone's dietary needs.

It's important for the nurse to provide teaching based on the client's specific needs and health conditions. In this case, the nurse can focus on maintaining hydration (based on the specific gravity result) and promoting a balanced diet and healthy lifestyle. Always individualize teaching based on the client's health status and any specific concerns they may have.

A. Call in additional medical-surgical unit nursing care staff. B. Recommend to the provider specific acute care clients for discharge. C. Determine the medical needs of incoming clients through the emergency department. D. Act as a liaison between the facility and the media.

Correct Answer is C

Explanation

A. While additional staffing might be necessary, the nurse's priority in a mass casualty event is to assess and provide care to incoming clients.
B. Discharging specific acute care clients may not be the immediate priority in a mass casualty event.
C. Correct. In a mass casualty event, the nurse should collaborate with the emergency department to determine the medical needs and prioritize care for incoming clients.
D. Acting as a liaison between the facility and the media may not be the immediate priority during a mass casualty event.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","D","G"]

Explanation

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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