A client expresses concern about the suctioning procedure. What is the best response by the nurse?
"You have nothing to worry about; the procedure is entirely safe.".
"Suctioning can be uncomfortable, but it helps maintain clear airways.".
"I understand your concern, but we have no other options to remove secretions.".
"Don't worry; I'll make sure to suction quickly to minimize any discomfort.".
The Correct Answer is B
Choice A rationale:
(Incorrect) Assuring the client that the procedure is entirely safe is not entirely accurate, as suctioning can carry some risks and discomfort.
Choice B rationale:
(Correct) This response acknowledges the client's concern about the suctioning procedure while providing a rationale for its importance, which is to maintain clear airways and prevent complications like airway blockage and respiratory distress.
Choice C rationale:
(Incorrect) Stating that there are no other options to remove secretions may not be true, and it does not address the client's concern effectively.
Choice D rationale:
(Incorrect) Promising to suction quickly may not address the client's worry and might compromise the effectiveness of the procedure, as thorough suctioning is necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale:
The nurse should not rotate the catheter between the thumb and forefinger during suctioning. This action could cause trauma to the airway.
Choice B rationale:
Limiting each suction pass to no more than 10 seconds is an essential practice during sterile suctioning. Prolonged suctioning can lead to hypoxia and potential complications.
Choice C rationale:
Rinsing the catheter and tubing with saline after each suction pass helps maintain patency and prevent the accumulation of secretions, ensuring effective suctioning during the procedure.
Choice D rationale:
Applying continuous suction while inserting the catheter is not recommended during sterile suctioning. Intermittent suction is preferred for safety and effectiveness.
Choice E rationale:
Providing encouragement and support to the client throughout the procedure is crucial for their comfort and cooperation. Suctioning can be uncomfortable, and the client may need reassurance during the process.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not discard the used catheter and gloves into a regular trash bin because they were used in a sterile procedure, and improper disposal could lead to the risk of contamination and infection for both the patient and others.
Choice B rationale:
Although it is important to assess the patient's response to suctioning, including vital signs, this should not be the immediate next step after completing sterile suctioning. First, the nurse should ensure their own and the patient's safety by following proper infection control measures.
Choice C rationale:
After completing sterile suctioning, the nurse should perform hand hygiene to prevent the spread of infection and then don a new pair of sterile gloves before performing any other tasks or assessments. This step ensures that the nurse maintains a sterile field and minimizes the risk of introducing pathogens into the patient's airway.
Choice D rationale:
Increasing the suction pressure for one last pass is not necessary and may cause harm to the patient's airway. Proper suctioning technique involves limiting the suctioning time and pressure to avoid tissue damage and potential complications.
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