When providing endotracheal suctioning, for how long should the nurse suction the endotracheal tube of an intubated client on a ventilator at a time?

Correct Answer: B

Rationale: When providing endotracheal suctioning, the nurse should suction for no longer than ten seconds at a time. Suctioning for longer than ten seconds may cause hypoxia or bronchospasm. Extended suctioning may also place the client at risk of injury to the bronchial and tracheal structures. Choices C and D suggest prolonged suctioning durations that can lead to adverse effects on the client. Choice A, suctioning for five seconds or less, may not be adequate to clear secretions effectively, making choice B the most appropriate duration for safe and efficient suctioning in this scenario.

Correct Answer: C

Rationale: The most appropriate action to reduce the risk of infection during the post-operative period is to remove the urinary catheter as soon as the client is ambulatory. Urinary catheters can serve as a source of bacteria, increasing the risk of infection in the bladder or urethra. By removing the catheter promptly once the client is mobile, the risk of infection can be minimized. Option A, flushing the central line with heparin, is not directly related to reducing urinary tract infections. Option B, administering narcotic analgesics as needed, is important for pain management but does not directly address infection prevention. Option D, ordering a high-protein diet, may be beneficial for wound healing but does not specifically target infection risk reduction in the post-operative period.

Correct Answer: A

Rationale: An incision that appears slightly red with a small amount of serous drainage on the first day following surgery is going through a normal healing process. It is important to keep the incision clean. In this case, the nurse should assist the client to shower as ordered to maintain hygiene and monitor for changes in the incision site. Instructing the client to lie prone may not be necessary and could cause discomfort. Applying antibiotic ointment without a specific order is not recommended as it can interfere with the healing process. Notifying the physician for an antibiotic order is premature at this stage since the incision is showing normal signs of healing.

Correct Answer: B

Rationale: Before administering platelets, it is crucial to check the integrity of the container holding the blood product. An intact container ensures the sterility and safety of the platelets, minimizing the risk of contamination or infection. Option A is incorrect as administering platelets typically does not require starting a new IV line unless indicated for the specific patient. Option C is not the priority as verifying the client's identity can be done at any point during the administration process but is not specific to the platelet transfusion itself. Option D, checking the client's chart for antibiotic use, is not directly related to ensuring the safety of the blood product container.

Correct Answer: B

Rationale: When a nurse's hand comes in contact with a client's blood, it is important to follow appropriate infection control measures. Using an alcohol-based hand sanitizer is not sufficient in this scenario as the blood is a visible contaminant. The best practice is to wash hands with soap and water using appropriate technique to ensure thorough cleansing and removal of any potential pathogens. Notifying the appropriate personnel about the exposure is important for documentation and further evaluation, but immediate hand hygiene is crucial. Sampling the client's blood for disease determination is not within the nurse's scope of practice and is unnecessary in this situation.