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 B
This action requires intervention by the staff nurse because waiting for 2 minutes between suctions is too long and can cause hypoxia, increased secretions, and infection. The recommended time interval between suctions is 30 to 60 seconds.
Choice A is wrong because Inserts the catheter without applying suction.
This is a correct action by the newly licensed nurse because applying suction while inserting the catheter can cause trauma to the tracheal mucosa. Suction should only be applied while withdrawing the catheter.
Choice C is wrong because Applies suction for 15 seconds. This is a correct action by the newly licensed nurse because applying suction for 15 seconds is within the recommended time limit of 10 to 15 seconds. Applying suction for longer than 15 seconds can cause hypoxia, bleeding, and cardiac arrhythmias.
Choice D is wrong because Encourages the client to cough during suctioning.
This is a correct action by the newly licensed nurse because encouraging the client to cough during suctioning can help loosen and mobilize secretions, making suctioning more effective and less traumatic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A client who is experiencing a panic attack has a very high level of anxiety and a diminished ability to focus. The nurse should stay with the client and remain calm and reassuring during the panic attack. This can help the client feel safe and supported, and reduce the intensity of the anxiety.
Choice A is wrong because atomoxetine is not an anti-anxiety medication, but a selective norepinephrine reuptake inhibitor (SNRI) used to treat attention deficit hyperactivity disorder (ADHD). It has no effect on reducing anxiety and can cause side effects such as insomnia, nausea, and increased blood pressure.
Choice B is wrong because encouraging the client to watch television is not a therapeutic intervention for a panic attack.
Watching television can increase the stimuli in the client’s environment, which can worsen anxiety.
The nurse should maintain an environment with low stimulation for the client experiencing a panic attack. Dim lighting, few people, and minimal distractions can assist the nurse to decrease the client’s level of anxiety.
Choice C is wrong because teaching the client how to meditate is not appropriate during a panic attack.
Meditation is a relaxation technique that can be helpful for preventing or reducing anxiety, but it requires concentration and focus, which are impaired in a panic attack. The nurse should teach the client how to meditate when the client is calm and receptive, not when the client is in crisis.
Correct Answer is A
Explanation
Absence seizures are brief, sudden lapses of consciousness that usually last a few seconds. They are more common in children than in adults.
A person having an absence seizure may stare blankly into space and not respond to others. They may also have subtle movements such as lip smacking or eyelid fluttering.
Choice B is wrong because absence seizures typically last less than 15 seconds, not 30 to 60 seconds.
Choice C is wrong because absence seizures have a sudden onset, not a gradual one.
Choice D is wrong because absence seizures do not have an aura prior to onset. An aura is a warning sign that some people experience before a seizure, such as a strange feeling, smell, or vision.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise, our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.