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 A
Explanation
A. Ecchymoses (bruising) over the buttocks and lower back in an older adult could be a sign of physical abuse or an underlying bleeding disorder, and it should be reported immediately.
B. Hirsutism, or increased facial and chest hair, is a common age-related change and does not usually require reporting unless it indicates an endocrine disorder.
C. Reduced skin elasticity is a normal age-related finding due to decreased collagen and elastin in aging skin.
D. Increased macules, or age spots, are benign and typical with aging, especially with prolonged sun exposure, and do not require reporting.
Correct Answer is D
Explanation
A. Asking each nurse for information about the problem is essential, but it should occur after addressing the immediate need for privacy.
B. Listening to the concerns of each staff nurse is important, but doing so in a private area ensures confidentiality and reduces further escalation.
C. Discussing ways to resolve the conflict is necessary, but first creating a safe and private environment is vital for open communication.
D. Moving the staff nurses to a private area is the first step to ensure they can discuss their conflict without external pressures or interruptions, which facilitates a more constructive dialogue.