NCLEX- RN QUESTIONS AND ANSWERS AND RATIONALE, 2023

NCLEX- RN QUESTIONS AND ANSWERS AND RATIONALE, 2023 The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions for this procedure? Select all that apply 1) Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is used. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently, to determine if suctioning is needed. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. Intermittent suction should be applied while the catheter is being withdrawn, not while it is being inserted. Suctioning should not be performed for longer than 10 seconds at one time to prevent cerebral hypoxia and a rise in intracranial pressure. Keeping a supply of suction catheters at the bedside 2. Auscultating breath sounds to determine the need for suctioning 3. Hyperoxygenating the client before, during, and after suctionin 3) The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. The cervix is dilated completely. The spontaneous urge to push is initiated from perineal pressure. Rationale: The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 from perineal pressure.