Restraints, Tach Care

Place in order, from first to last, the actions the nurse will perform when preparing to suction an alert client via tracheostomy using an open system. Use all options.

1. Explain the procedure to the client 2. Adjust the bed and position the client 3. Adjust the wall suction to the appropriate level 4. Open sterile packages and set up sterile field 5. Don sterile gloves 6. Auscultate the client's lung sounds for evaluation of the intervention

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure? A. Extremity restraint B. Mummy restraint C. Elbow restraint D. Waist restraint

A. Extremity restraint

When suctioning a client with a tracheostomy using an open system, which actions by the nurse would help to prevent hypoxemia during the procedure? Select all that apply. A. Limit suctioning to 10-15 seconds each time. B. Pause for 30-60 seconds between suctioning attempts C. Maintain sterile technique at all times during the procedure D. Use sterile saline to clear the suction tubing E. Hyperventilate the client with 3-6 breaths before suctioning

A. Limit suctioning to 10-15 seconds each time. B. Pause for 30-60 seconds between suctioning attempts E. Hyperventilate the client with 3-6 breaths before suctioning

On assessment, the nurse notes that the tracheostomy ties are grossly soiled and require changing. No one is available to assist at this time. What is the best action by the nurse? A. Remove the soiled ties and tape the tracheostomy collar securely in place B. Secure the new tracheostomy ties before removing the old ties C. Wait until later when someone is available to assist with the change D. Instruct the client in the importance of not coughing during the procedure

A. Remove the soiled ties and tape the tracheostomy collar securely in place

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? A. The alternative measures attempted before applying the restraints B. A detailed description of the restraint application process C. Verbal prescription for the restraints, renewed every 48 hours D. The type of PPE used by the nurse during restraint application

A. The alternative measures attempted before applying the restraints

Which client is most likely to need administration of pain medication before being suctioned via the tracheostomy? A. The client with diabetes mellitus B. The client who had abdominal surgery C. The client with bilateral pneumonia D. The client who had a toe amputation

B. The client who had abdominal surgery

The nurse is preparing to provide tracheostomy care to a client. The client's tracheostomy dressing is soiled, but a commercially prepared tracheostomy dressing is not available. Which action should the nurse perform? A. Apply water-soluble lubricant around the stoma B. Use two folded gauze sponges on each side of the stoma C. Cut a small slit in a sterile gauze pad D. Wait until a commercially prepared dressing becomes available

B. Use two folded gauze sponges on each side of the stoma

The nurse is inserting the suction catheter into a client's tracheostomy and suddenly meets resistance. Which action would be most appropriate? A. Apply suction to the catheter B. Withdraw the catheter at least 0.5 inch C. Rotate the catheter one half-turn D. Continue inserting the catheter another inch

B. Withdraw the catheter at least 0.5 inch

On assessment, the nurse notes significant secretions on the client's tracheostomy dressing. The health care provider's prescription states that tracheostomy site care is to be done once per shift. The nurse has already performed site care once during the current shift. What is the best action by the nurse? A. Wipe the secretions off the dressing as best as possible B. Notify the health care provider and request additional prescription C. Perform site care again and document the procedure D. Request that the nurse on the next shift change the dressing

C. Perform site care again and document the procedure

When preparing to suction a client's tracheostomy, which action by the nurse best helps to prevent the introduction of microorganisms into the respiratory tract? A. Gently rotating the suction catheter as it is being withdrawn B. Using only the dominant hand to open and close the suction port C. Using only the dominant hand to handle and manipulate the catheter D. Applying suction only during insertion of the suction catheter

C. Using only the dominant hand to handle and manipulate the catheter

The nurse is preparing to provide tracheostomy care to a client with a new tracheostomy. Which action should the nurse take before beginning the procedure? A. Hyperventilate the client with a resuscitation bag B. Apply a topical analgesic around the tracheostomy stoma site C. Ensure that any oxygen source is tightly secured to the tracheostomy D. Assess the client for pain and administer analgesic as needed

D. Assess the client for pain and administer analgesic as needed