A home health nurse is teaching about endotracheal suctioning. Which of the following information should the nurse include in the teaching?
Allow the client to rest for 10 to 15 seconds after each suctioning attempt.
Set the suction pressure to 110 mm Hg
Apply suction for less than 10 seconds.
Apply suction when inserting the catheter.
Correct Answer : A,C
A) Allow the client to rest for 10 to 15 seconds after each suctioning attempt: Allowing the client to rest between suctioning attempts helps to minimize hypoxemia and reduces the risk of trauma to the airway mucosa. It also allows the client to recover from the physiological stress of suctioning before initiating another attempt.
C) Apply suction for less than 10 seconds: Prolonged suctioning can lead to hypoxemia and tissue trauma. The nurse should limit suctioning to less than 10 seconds per pass to minimize these risks and prevent complications such as mucosal damage and bleeding.
B) Set the suction pressure to 110 mm Hg: The appropriate suction pressure for endotracheal suctioning depends on various factors, including the client's age, condition, and clinical status. While suction pressures of 80 to 120 mm Hg are commonly used for adults, the specific pressure setting should be individualized based on the client's needs and should not exceed the safe range to prevent mucosal injury or hypoxemia.
D) Apply suction when inserting the catheter: Suction should be applied only during withdrawal of the catheter to minimize the risk of mucosal trauma and hypoxemia. Applying suction during catheter insertion can increase the risk of airway trauma and should be avoided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Collect a urine sample from the client: While collecting a urine sample may be necessary for further assessment, it is not the priority in this situation. The client's symptoms of lower back pain, feeling chilled, and itching suggest a potential transfusion reaction, which requires immediate attention to ensure the client's safety. Therefore, collecting a urine sample is not the most appropriate initial action.
B. Return the platelet bag and tubing to the blood bank: Returning the platelet bag and tubing to the blood bank may be necessary after stopping the infusion, but it is not the first action the nurse should take. Stopping the infusion and assessing the client's condition are the immediate priorities to address the potential transfusion reaction.
C. Notify the provider: While it is important to notify the provider about the client's symptoms and the suspected transfusion reaction, this action should follow after stopping the infusion and assessing the client's condition. Immediate intervention to ensure the client's safety takes precedence over contacting the provider.
D. Stop the infusion: This is the correct action. The client's symptoms of lower back pain, feeling chilled, and itching are indicative of a potential transfusion reaction, such as febrile non-hemolytic transfusion reaction or allergic reaction. The immediate priority is to stop the infusion to prevent further administration of platelets and assess the client's condition. This action takes precedence over other interventions as addressing the client's safety and well-being is paramount in the event of a transfusion reaction.
Correct Answer is B
Explanation
A. Excessive thirst and urination:
Excessive thirst and urination are symptoms typically associated with hyperglycemia, where there is a high level of glucose in the blood, often related to diabetes. When TPN is stopped suddenly, the concern is more about hypoglycemia due to the abrupt lack of glucose infusion, not hyperglycemia.
B. Shakiness and diaphoresis:
When TPN is suddenly interrupted, the continuous supply of glucose that the patient relies on is abruptly halted. This can lead to a rapid drop in blood sugar levels, causing hypoglycemia. Symptoms of hypoglycemia include shakiness, diaphoresis (sweating), confusion, and even loss of consciousness if not promptly addressed. Monitoring for shakiness and diaphoresis is crucial in this scenario to prevent severe hypoglycemia.
C. Hypertension and crackles:
These symptoms are typically indicative of fluid overload or heart failure. While TPN can contribute to fluid overload if not managed properly, the immediate concern with the cessation of TPN is the lack of glucose and potential hypoglycemia, not fluid overload.
D. Fever and chills:
Fever and chills are generally signs of an infection, such as sepsis. While infections can be a complication of TPN due to the intravenous route of administration, they are not directly related to the sudden stopping of TPN. The primary concern when TPN stops unexpectedly is the risk of hypoglycemia due to the cessation of glucose infusion.
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