Which of these steps is essential when the nurse is preparing to suction a client's tracheostomy?

a. Administer oxygen or use an Ambu bag before beginning procedure.
b. Change the client's inner cannula.
c. Cover the tracheostomy ties with a clean towel.
d. Set up sterile hydrogen peroxide to use for rinsing the suction catheter.


A
Prior to performing suctioning, administer oxygen or use Ambu bag to hyperventilate the client, preventing hypoxemia.

Nursing

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Which of the following are the responsibilities of the delegatee in a situation (select all that apply)?

a. Corrective action b. Own acts c. Accepting the delegation d. Appropriate notification and reporting e. Accomplishing the task

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An infant had been diagnosed with impetigo. Nursing care should include:

a. Cleaning lesions once a day to remove crusts b. Administration of IV antibiotics c. Using aseptic methods to prevent spread of the disease d. Allowing the infant to scratch the lesions to provide relief

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A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." Which is the nurse's best response?

a. "I wonder what this sudden change is all about. Please tell me more." b. "I am glad you are feeling better. The team will consider your request." c. "You should not try to direct your care. Leave that to the treatment team." d. "Because we are concerned about your safety, we will continue with our plan."

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A client with OCD tells the nurse, "Thinking these thoughts and doing all my rituals is beyond being silly. I know others laugh behind my back. I sometimes think I can control things, but I al-ways find I can't

I don't know if I can continue to live this way…being a burden on my family and being of no use to myself." The reply that shows the best understanding of the client's priority risk is: 1. "How are you sleeping?" 2. "Are your rituals interfering with eating?" 3. "Have you been thinking about suicide? 4. "What makes you think others are laughing behind your back?

Nursing