A client with a history of bleeding disorder requires suctioning. Which statement indicates that the nurse should not proceed with the procedure?
"I have some mild nasal congestion.".
"My throat feels a bit sore.".
"I have been coughing up blood.".
"I feel a little lightheaded.".
The Correct Answer is C
"I have been coughing up blood.”.
Choice A rationale:
Mild nasal congestion may be a common finding in many patients and does not necessarily contraindicate suctioning unless it significantly obstructs the airway.
Choice B rationale:
A sore throat may indicate local irritation, but it does not directly contraindicate suctioning unless there are other underlying complications.
Choice C rationale:
A history of coughing up blood (hemoptysis) suggests an ongoing bleeding disorder. Suctioning could exacerbate the bleeding, leading to further complications. The procedure should be avoided until the cause of hemoptysis is properly assessed and managed.
Choice D rationale:
Feeling lightheaded may be a common sensation during and after suctioning due to the stimulation of the gag reflex, but it does not necessarily contraindicate the procedure. It is essential to ensure adequate oxygenation and provide proper support during the procedure to minimize this discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
(Incorrect) Stating that it's common for oxygen saturation to drop during suctioning is not appropriate because a drop in oxygen saturation is an abnormal response that requires immediate intervention.
Choice B rationale:
(Incorrect) Telling the patient that a drop in oxygen levels is a normal response and will improve soon is incorrect and may lead to delay in addressing the potential respiratory distress.
Choice C rationale:
(Correct) This response is appropriate because the nurse should stop suctioning immediately if the patient's oxygen saturation drops below the normal range and provide supplemental oxygen to maintain adequate oxygenation.
Choice D rationale:
(Incorrect) Advising the patient to take slow deep breaths to increase oxygen levels may not be sufficient to address the oxygen saturation drop, which requires immediate intervention.
Correct Answer is D
Explanation
Choice D rationale:
When suctioning patients with an artificial airway, using disposable plastic catheters is preferred to reduce the risk of infection. Disposable catheters are single-use and discarded after each procedure, minimizing the potential for contamination and cross-infection between patients.
Choice A rationale:
Glass suctioning catheters are not preferred because they cannot be effectively sterilized for reuse. Reusable materials carry a higher risk of infection transmission and should be avoided when possible.
Choice B rationale:
Metal suctioning catheters are also not the preferred choice for reducing the risk of infection. Like glass catheters, they can be difficult to clean and sterilize adequately for safe reuse. Using disposable materials, like plastic catheters, is a safer option.
Choice C rationale:
While reusable silicone catheters may be more flexible and gentler on the airway, they are not the preferred choice for infection control. Like other reusable materials, they carry a higher risk of contamination and are not as easily disposed of as disposable plastic catheters.
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