A nurse is supervising a newly licensed nurse who is suctioning a client who has a tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
Waits 2 min between suction passes.
Wears clean gloves during suctioning.
Turns the pressure on the suction to 200 mm Hg.
Applies suction while inserting the catheter.
The Correct Answer is A
A. Waiting 2 minutes between suction passes allows the client to recover and helps to prevent hypoxia, demonstrating an understanding of the suctioning procedure.
B. Wearing clean gloves during suctioning is not appropriate; sterile gloves should be used to prevent introducing pathogens into the airway.
C. The recommended suction pressure for adults is typically between 80 and 120 mm Hg; therefore, setting the suction to 200 mm Hg is too high and could cause trauma to the airway.
D. Suction should be applied only while withdrawing the catheter, not while inserting it, to minimize trauma and prevent oxygen deprivation.
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Correct Answer is C
Explanation
A. Administering pain medication before ambulation is an example of patient-centered care and pain management but does not specifically demonstrate fidelity, which relates to keeping promises and being trustworthy.
B. Stopping feeding when a client becomes short of breath is an appropriate response to prevent aspiration, but it is not an example of fidelity.
C. Telling a client she will return with a medication and following through with that commitment demonstrates fidelity by fulfilling a promise and showing reliability.
D. Dividing time and care between clients is part of effective time management, but it does not specifically represent fidelity, which emphasizes keeping promises to clients.
Correct Answer is D
Explanation
A. Notifying the nurse manager is important, but it is not the immediate priority when a family member has fainted.
B. Completing an incident report is necessary for documentation but should occur after addressing the immediate medical concern.
C. Obtaining the family member's health history is not pertinent at this moment as the priority is to assess their current condition.
D. Checking the family member's vital signs is the first action to determine their immediate health status and any necessary interventions to provide appropriate care.