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

Discard the used catheter and gloves into a regular trash bin.

Assess the patient's response to suctioning, including vital signs.

Perform hand hygiene and don a new pair of sterile gloves.

Increase the suction pressure for one last pass to ensure thorough cleaning.

Answer and Explanation

The Correct Answer is C

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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Correct Answer is ["A","D","E"]

Explanation

Choice A rationale:

Environmental cleaning before suctioning is crucial to maintain a clean and safe environment for the patient. This reduces the risk of introducing additional contaminants during the procedure.

Choice B rationale:

Using a reusable suctioning catheter is not appropriate for infection control measures. Reusable catheters can harbor microorganisms, even after proper cleaning and sterilization, increasing the risk of cross-contamination.

Choice C rationale:

Proper disposal of used catheters into a regular trash bin is not a suitable infection control measure. Used catheters should be disposed of in designated biohazard containers to prevent exposure to potential pathogens.

Choice D rationale:

Hand hygiene before and after the procedure is essential to reduce the transmission of microorganisms to and from the patient.

Choice E rationale:

Wearing gloves and a mask during suctioning helps protect the nurse from exposure to the patient's bodily fluids and potential infectious agents.

Repeat steps 7 to 9 until no more secretions are obtained or until three passes are completed. Do not suction more than three times in a row to prevent complications. Allow at least one minute of rest between each suction pass to prevent fatigue and distress .

A. Reposition the patient and ensure safety. B. Document the procedure and findings. C. Remove the catheter and tubing from the artificial airway. D. Assess the patient's response to suctioning.

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.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

(Select all that apply - Online ATI/HESI question): A nurse is performing sterile suctioning on a patient. Which of the following are appropriate infection control measures for this procedure? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

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

During sterile suctioning, the nurse observes the patient experiencing bronchospasm and increased intracranial pressure. What should be the nurse's immediate action?

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?

(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.

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?

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

(Select all that apply): A nurse is preparing to perform sterile suctioning on a patient. Which of the following are types of suctioning catheters commonly used for this procedure? Select all that apply.