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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
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.
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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