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 C

Explanation

Choice C rationale:

The nurse should acknowledge the patient's anxiety and respond empathetically. Assuring the patient that the nurse will explain each step during the procedure can help alleviate anxiety. This approach promotes trust and helps the patient feel more in control, which is important for patient cooperation during the suctioning procedure.

Choice A rationale:

Telling the patient not to worry and that it won't take long may come across as dismissive and not address the patient's concerns adequately.

Choice B rationale:

Offering to postpone the procedure is an option, but the nurse should first attempt to address the patient's anxiety and provide reassurance. If the anxiety persists despite the explanation, postponing the procedure can be considered.

Choice D rationale:

Dismissing the patient's anxiety by stating that suctioning is routine may not effectively address the patient's feelings and may not be comforting.

A. Limit each suction pass to no more than 10 seconds. B. Apply suction while inserting the catheter. C. Rotate the catheter between thumb and forefinger. D. Rinse the catheter and tubing with saline after each suction pass. E. Suction more than three times in a row for thorough cleaning.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale:

The nurse should limit each suction pass to no more than 10 seconds to minimize the risk of tissue damage and hypoxia. Prolonged suctioning can cause trauma to the mucosa and lead to inadequate oxygenation.

Choice B rationale:

The nurse should apply suction while inserting the catheter to prevent the catheter from touching the airway walls before suction is initiated. This helps avoid stimulating the gag reflex and causing discomfort to the client.

Choice C rationale:

Rotating the catheter between the thumb and forefinger helps to facilitate even suctioning and prevent the catheter from adhering to the airway walls. It allows for effective removal of secretions without causing harm to the delicate tissues.

Choice D rationale:

After each suction pass, the nurse should rinse the catheter and tubing with saline to maintain its patency and prevent the buildup of secretions. This practice ensures that subsequent suctions are effective in clearing the airway.

Choice E rationale:

Suctioning more than three times in a row is not recommended because it can lead to hypoxia and tissue trauma. Frequent suctioning can reduce the oxygen levels in the airway and cause damage to the delicate tissues.

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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 is about to perform sterile suctioning and asks the patient if they are ready. The patient responds, "I am feeling very anxious about this.” What would be the appropriate response from the nurse?

Correct Answer is C

Explanation

(Select all that apply): A client requires sterile suctioning through a tracheostomy tube (TT). What steps should the nurse follow during the suctioning procedure? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

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 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 nurse is preparing to perform sterile suctioning for a patient with an endotracheal tube (ETT). What should the nurse do before suctioning?

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

When suctioning a patient with an endotracheal tube (ETT), the nurse should limit the suctioning time to:

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

A nurse is educating a group of patients about sterile suctioning. Which patient statement indicates a contraindication for this procedure?

(Online ATI/HESI question): A nurse is preparing to suction a patient with thick secretions. Which type of suctioning catheter should the nurse choose to effectively aspirate the secretions?