The nurse recognizes that the most appropriate reason to suction a client is that:
suctioning once every eight hours is a part of routine pulmonary nursing care.
the physician has prescribed suctioning every hour.
the client has thick sputum, and routinely coughs and swallows his sputum.
the client has gurgling respirations, and is unable to cough.
The Correct Answer is D
Choice A rationale: Suctioning is not typically performed as part of routine pulmonary nursing care every eight hours. It is indicated based on the client's clinical need.
Choice B rationale: Suctioning frequency should be determined by the client's condition and physician's orders, not a fixed hourly schedule.
Choice C rationale: Routine coughing and swallowing of sputum do not necessarily warrant suctioning. Suctioning is indicated when the client is unable to manage secretions effectively.
Choice D rationale: Suctioning is appropriate when the client has gurgling respirations and is unable to cough effectively, indicating the need to clear the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Shared responsibility is a necessary feature of a team, promoting collaboration and achievement of common goals.
Choice B rationale: Mutual independence allows team members to work together while maintaining individual contributions.
Choice C rationale: Working in the same department is not a necessary feature of a team. Teams can be effective regardless of their physical proximity.
Choice D rationale: Common purpose is essential for a team to work cohesively toward shared goals.
Correct Answer is C
Explanation
Choice A rationale: Telling the nurse manager is not the first action; the immediate focus should be on the client's well-being.
Choice B rationale: Notifying the physician is important, but the immediate concern is addressing the client's condition.
Choice C rationale: Checking the client's blood pressure is the first action to assess the client's response to the medication error.
Choice D rationale: Filing an incident report is important for documenting the error but is not the immediate action in this situation.
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