Difficulty: Medium
Average Score: 81%
Simulated
A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?
Correct answer
A
Rationale
The correct answer is A because suctioning a client's tracheostomy for 15 seconds is too long and can lead to hypoxia. The optimal suctioning time for a tracheostomy is usually 5-10 seconds to prevent hypoxia. Encouraging the client to cough during suctioning (choice B) helps to remove secretions effectively. Waiting for 2 minutes between suctions (choice C) allows the client to recover and prevents damage to the airway. Inserting the catheter without applying suction (choice D) indicates the nurse is not effectively clearing secretions.