An infant client has a tracheostomy. The nurse prepares to suction the tracheostomy. Which most important principle does the nurse use to plan care?

Suctioning must follow a set schedule every two hours

Coughing helps loosen secretions before suctioning

A strict sterile technique is always required for suctioning

Suction pressure time and catheter size are critical

Answer and Explanation

The Correct Answer is D

It is important to use the appropriate suction pressure, time, and catheter size when suctioning a tracheostomy to prevent injury and ensure eﬀective removal of secretions.

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

Explanation

These are all important steps in rendering prescribed wound care for a child with an abdominal wound. Measuring the size of the wound helps to track healing progress. Working outward from the incision and wiping from a clean area to a less clean area helps to prevent infection.

A. The nurse provides written and verbal instructions prior to discharge. When at home the client began to take the wrong medication. B. The nurse hangs a new bag of IV ﬂuids 1 hour early and does not count what is remaining in the bag on the ﬂuid record. C. The nurse gives medication to another nurse to give to a client and the wrong client receives the medication and becomes ill. D. A client becomes confused and combative and pulls out the IV. The nurse calls the health care provider to change the behavior.

Correct Answer is C

Explanation

Negligence is a failure to act in a reasonable and prudent manner that results in harm or injury to another person. In option c), the nurse did not exercise reasonable care in ensuring that the medication was given to the correct patient, which resulted in harm to the wrong patient.

The other options (a, b, and d) do not involve a failure to act in a reasonable and prudent manner that caused harm or injury to the client. In option a), the nurse provided written and verbal instructions, but the client did not follow them, which is beyond the nurse's control.

In option b), the nurse made an error in documenting the ﬂuid count, which is a documentation error, not negligence. In option d), the nurse acted appropriately by calling the healthcare provider to change the client's behavior, and the situation does not involve negligence.

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An infant client has a tracheostomy. The nurse prepares to suction the tracheostomy. Which most important principle does the nurse use to plan care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides care for a child with an abdominal wound. The wound edges are approximated. Which does the nurse include when rendering the prescribed wound care to this child? (Select all that apply)

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

Explanation

In which situation is the nurse determined to be negligent?

Correct Answer is C

Explanation

The nurse instructs the client on the use of an incentive spirometer. Which observation indicates to the nurse that additional teaching is required?

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