when suctioning a client what is the usual amount of time the nurse should spend for each suction pass
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Nursing Elites

NCLEX-PN

Nclex Exam Cram Practice Questions

1. When suctioning a client, what is the usual amount of time the nurse should spend for each suction pass?

Correct answer: B

Rationale: Ten seconds is the usual amount of time the nurse should spend for each suction pass. Two seconds is not enough time to effectively remove secretions, while 20 and 30 seconds are too long and could lead to hypoxia and tissue trauma. Therefore, the correct choice is 10 seconds, as it strikes a balance between removing secretions adequately and minimizing the risks associated with prolonged suctioning.

2. How is the information documented on incident reports used?

Correct answer: D

Rationale: The information documented on incident reports is used for various purposes, including analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs. Incident reports provide valuable data that can be utilized in risk management, quality monitoring, and improvement programs. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all correct as incident reports are used for analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs, respectively. Thus, the most comprehensive answer is 'all of the above.'

3. A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?

Correct answer: C

Rationale: When a client in skeletal traction complains of pain, the priority action for the nurse is to realign the client. Severe pain may indicate the need for realignment or that the traction weights are too heavy. Realigning the client should be the initial response as it can help alleviate the pain by ensuring proper alignment. Asking the client to wiggle their toes may not address the underlying issue causing the pain. Removing traction weights should never be done unless specifically ordered by the healthcare provider as it can affect the traction's effectiveness. Medicating the client with analgesics should only be considered after attempting to address the cause of the pain, which in this case, is realignment.

4. Which of the following is not one of the four categories related to client care plans?

Correct answer: A

Rationale: The four categories related to client care plans are diagnosis, intervention, outcome, and evaluation. Privacy is not typically considered a distinct category in client care plans, as it is more of a fundamental aspect that underlies all care provided to clients. Choices B, C, and D are directly related to the components of client care plans, making them incorrect answers in this context.

5. The nurse is teaching a client about erythema infectiosum. Which of the following factors is not correct?

Correct answer: B

Rationale: The correct answer is that the disorder is uncommon in adults. Erythema infectiosum, also known as Fifth's disease, commonly affects children and is characterized by a 'slapped face' appearance. It is associated with a rash and sometimes a low-grade fever. Therefore, the statement 'The disorder is uncommon in adults' is not correct, making it the correct answer. The other statements about the presence of a rash, 'slapped face' appearance, and the possibility of a fever are accurate in the context of erythema infectiosum.

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