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
None
None
The Correct Answer is B
The correct answer is choice b. Waits for 2 min between suctions.
Choice A rationale:
Inserting the catheter without applying suction is correct. Suction should only be applied while withdrawing the catheter to prevent trauma to the tracheal mucosa.
Choice B rationale:
Waiting for 2 minutes between suctions is too long. The appropriate wait time is generally around 20-30 seconds to 1 minute between suction attempts to prevent hypoxia and allow the patient to recover.
Choice C rationale:
Applying suction for 15 seconds is within the recommended duration. Suctioning should not exceed 15 seconds to avoid causing hypoxia and trauma to the tracheal mucosa.
Choice D rationale:
Encouraging the client to cough during suctioning is appropriate. Coughing helps to mobilize secretions and can make suctioning more effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
B, C, and E. The nurse should include the following statements in the teaching:.
-
- You should eat foods that are low in fat. A low-fat diet can help reduce the amount of digestive enzymes your pancreas releases and prevent further inflammation and pain.
- Notify your provider if you experience vomiting or diarrhea. These symptoms can lead to dehydration and malnutrition, which can worsen your condition and require hospitalization.
- You should eat foods high in protein. Protein can help your body heal and repair damaged tissues. It can also prevent muscle wasting and weight loss, which are common complications of chronic pancreatitis.
Choice A is wrong because caffeine can stimulate the pancreas and increase pain and inflammation. Choice D is wrong because alcohol can damage the pancreas and trigger more attacks. People with chronic pancreatitis should avoid alcohol completely.
Correct Answer is A
Explanation
Encourage collaboration between the two nurses when making the assignments. This is because collaboration is one of the most effective conflict-resolution strategies in nursing, as it involves finding a mutually beneficial solution that satisfies both parties and improves the quality of care. Collaboration can also foster trust, respect, and teamwork among nurses, which can boost morale and efficiency.
Choice B is wrong because telling the nurses that the assignments will be more equitable in the future does not address the root cause of the conflict or involve the nurses in the decision-making process.
It also implies that the charge nurse admits to being unfair, which can damage their credibility and authority.
Choice C is wrong because asking each nurse to take turns making the assignments does not resolve the conflict, but rather avoids it. Avoidance is one of the least effective conflict management strategies in nursing, as it results in not addressing the issue or finding a common ground.
Avoidance can also lead to resentment, frustration, and poor communication among nurses.
Choice D is wrong because arranging for the nurses to have as few shifts together as possible also does not resolve the conflict, but rather accommodates it. Accommodation is another ineffective conflict management strategy in nursing, as it involves giving in to one party’s demands or preferences at the expense of another’s.
Accommodation can also create a sense of inequality, injustice, and dissatisfaction among nurses.
Normal ranges for conflict-resolution strategies in nursing are not applicable, as different situations may require different approaches.
However, some general guidelines are to use collaboration when both parties have important goals or interests, compromise when both parties have some common ground or willingness to give up something, competition when one party has a clear advantage or authority, avoidance when the conflict is trivial or temporary, and accommodation when one party values harmony or relationships more than their own goals or interests.
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