A client is undergoing sterile suctioning. Which interventions should the nurse implement during the suctioning procedure? Select all that apply.

Rotate the catheter between the thumb and forefinger during suctioning.

Limit each suction pass to no more than 10 seconds.

Rinse the catheter and tubing with saline after each suction pass.

Apply continuous suction while inserting the catheter.

Provide encouragement and support to the client throughout the procedure.

Answer and Explanation

Correct Answer : B,C,E

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.

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Correct Answer is A

Explanation

Choice A rationale:

(Correct) After sterile suctioning, it is essential to reposition the patient to a comfortable and safe position, ensuring proper alignment and support to prevent complications.

Choice B rationale:

(Incorrect) While documentation is crucial, ensuring the patient's safety and comfort should be the immediate priority after the procedure.

Choice C rationale:

(Incorrect) The nurse should not remove the catheter and tubing from the artificial airway immediately after suctioning, as it may still be needed for subsequent interventions.

Choice D rationale:

(Incorrect) Assessing the patient's response to suctioning is essential, but ensuring safety and repositioning take precedence immediately after the procedure.

A. Clean the inner cannula once a week. B. Deflate the cuff before cleaning the tube. C. Use cotton-tipped applicators to clean the stoma. D. Change the tracheostomy ties every 24 hours.

Correct Answer is D

Explanation

Choice A rationale:

Cleaning the inner cannula once a week is insufficient to maintain proper hygiene for a patient with a tracheostomy tube. The inner cannula should be cleaned more frequently, as directed by the healthcare provider, to prevent the accumulation of secretions and potential respiratory complications.

Choice B rationale:

Deflating the cuff before cleaning the tracheostomy tube is not recommended because it may lead to aspiration of secretions or loss of the airway seal. The cuff should only be deflated when it is necessary to remove or change the tracheostomy tube.

Choice C rationale:

Using cotton-tipped applicators to clean the stoma is not the recommended method for tracheostomy care. Sterile tracheostomy care kits usually include specialized brushes or swabs designed for this purpose, ensuring effective and safe cleaning of the stoma without the risk of shedding fibers or causing injury.

Choice D rationale:

Changing the tracheostomy ties every 24 hours is the appropriate action. Regular changing of the ties helps prevent complications such as skin breakdown, ensures a secure fit of the tracheostomy tube, and reduces the risk of infection.

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A client is undergoing sterile suctioning. Which interventions should the nurse implement during the suctioning procedure? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has completed sterile suctioning for a patient. What should be the nurse's next action after suctioning?

Correct Answer is A

Explanation

A nurse is performing tracheostomy care for a patient with a tracheostomy tube (TT). Which action should the nurse include in the procedure?

Correct Answer is D

Explanation

A nurse is performing sterile suctioning on a patient with an artificial airway. What is the purpose of sterile suctioning?

A nurse has completed sterile suctioning for a patient with an endotracheal tube (ETT). What should the nurse do next?

A nurse is teaching infection control principles for sterile suctioning. Which measure is the most important to prevent cross-contamination during the procedure?

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A nurse is performing sterile suctioning and observes the patient's oxygen saturation dropping below the normal range. Which statement by the nurse is appropriate?

A client has a nasopharyngeal tube (NPT) for oxygenation. During the suctioning procedure, the patient says, "I'm experiencing discomfort in my nose.” How should the nurse respond?

A client with a history of bleeding disorder requires suctioning. Which statement indicates that the nurse should not proceed with the procedure?

(Select all that apply): A nurse is preparing to perform nasopharyngeal suctioning for a patient with a nasopharyngeal tube (NPT). What actions should the nurse take during the procedure? Select all that apply.