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D.   The catheter should be attached to suction while being inserted and withdrawn to effectively clear secretions from the airway.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

Explanation

A. Incorrect. Clear liquids are usually introduced slowly and progressively, but 6 hours postoperative might be too soon for this intervention.

B. Incorrect. Cromolyn nebulized solution is used to prevent asthma symptoms triggered by certain factors, not for postoperative care.

C. Incorrect. Applying a warm compress to the operative site might not be appropriate for the immediate postoperative period, especially in the case of appendicitis.

D. Correct. Administering analgesics on a scheduled basis helps manage postoperative pain and provides effective pain relief, promoting comfort and recovery.

A. Clean the equipment with an alcohol-based cleaning product. B. Apply petroleum jelly to soothe the mucous membranes. C. Use synthetic fabrics for the client's bedding. D. Avoid using nail polish remover around the client.

Correct Answer is D

Explanation

A. Alcohol-based cleaning products are flammable and should not be used near oxygen equipment.
B. Petroleum jelly is also flammable and should not be applied to the client's face when using oxygen therapy.
C. Synthetic fabrics cangenerate static electricity, which could potentially lead to a fire hazard in the presence of oxygen.
D. Nail polish remover is flammable and should be avoided near oxygen equipment.

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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?

Nursing Test Bank

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