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?
Inserts the catheter without applying suction.
Waits for 2 min between suctions.
Applies suction for 15 seconds.
Encourages the client to cough during suctioning.
The Correct Answer is C
The correct answer is **c. Applies suction for 15 seconds**.
**Choice A rationale:** Inserting the catheter without applying suction is a proper step in the suctioning process. This action does not require intervention by the staff nurse.
**Choice B rationale:** 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.
**Choice C rationale:** Applying suction for 15 seconds is too long and can cause damage to the trachea. The recommended duration for suctioning is typically 5-10 seconds. This action requires intervention by the staff nurse to correct the procedure and ensure the client's safety.
**Choice D rationale:** Encouraging the client to cough during suctioning is a proper step to help clear the trachea and promote effective suctioning. This action does not require intervention by the staff nurse.
In summary, the newly licensed nurse's action of applying suction for 15 seconds is the one that requires intervention by the staff nurse to correct the procedure and ensure the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This instruction will help the client to prevent venous stasis and thrombosis, which are common postoperative complications. Range-of-motion exercises promote blood circulation and prevent muscle atrophy and contractures.
Choice B is wrong because “Use an incentive spirometer every 4 hours.” is wrong because it is not related to promoting circulation, but rather to improving lung expansion and preventing atelectasis and pneumonia. Using an incentive spirometer is also important for postoperative clients, but it does not address the question.
Choice C is wrong because “Remain on bed rest for 24 hours following the procedure.” is wrong because it is the opposite of promoting circulation.
Bed rest increases the risk of venous stasis, thrombosis, and pulmonary embolism. Postoperative clients should be encouraged to ambulate as soon as possible, unless contraindicated.
Choice D is wrong because “Place a pillow under your knees while in bed.” is wrong because it also impairs circulation and increases the risk of thrombosis.
Placing a pillow under the knees can cause pressure on the popliteal veins and reduce blood flow. Postoperative clients should avoid this position and keep their legs in a neutral or slightly elevated position.
Correct Answer is A
Explanation
The nurse should ensure the state health department has been notified of the child’s Lyme disease, as it is a reportable disease in most states. Reporting helps to monitor the incidence and prevalence of Lyme disease and to implement prevention and control measures.
Choice B is wrong because antitoxin is not used to treat Lyme disease.
Antitoxin is a substance that neutralizes the effects of a toxin, such as botulism or tetanus. Lyme disease is caused by a bacterium called Borrelia burgdorferi, which can be treated with antibiotics.
Choice C is wrong because Lyme disease is not transmitted by sharing personal belongings. Lyme disease is spread to humans by the bite of infected ticks that carry the bacterium. The risk of getting Lyme disease can be reduced by avoiding tick-infested areas, wearing protective clothing, using insect repellent, and removing ticks promptly.
Choice D is wrong because skin necrosis is not a common complication of Lyme disease.
Skin necrosis is the death of skin tissue due to lack of blood supply or infection. Lyme disease can cause a characteristic skin rash called erythema migrans, which is usually circular or oval and expands over time. Other possible signs and symptoms of Lyme disease include fever, headache, fatigue, joint pain, and neurological problems.
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