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 D

Explanation

Choice D rationale:

The nurse should respond by acknowledging the discomfort and pausing the procedure to reposition the nasopharyngeal tube. Repositioning can help alleviate the discomfort while ensuring the oxygenation needs are still met.

Choice A rationale:

Increasing the suction pressure may exacerbate the discomfort and cause further irritation to the nose and airway.

Choice B rationale:

Instructing the client to breathe through the mouth may not adequately address the discomfort and may not be feasible if the oxygenation is dependent on the nasopharyngeal tube.

Choice C rationale:

Although explaining the necessity of suctioning is important, it does not directly address the client's immediate discomfort. The priority is to address the client's comfort and safety during the procedure.

A. "I have a history of epiglottitis.". B. "I sometimes get laryngeal edema.". C. "I have difficulty clearing my secretions.". D. "I use an artificial airway at night.".

Correct Answer is A

Explanation

Choice A rationale:

Epiglottitis is an inflammation of the epiglottis, which is a crucial structure in protecting the airway during swallowing. Suctioning in patients with a history of epiglottitis can be dangerous because it can cause further irritation and swelling of the epiglottis, potentially leading to airway obstruction and respiratory distress. Therefore, sterile suctioning is contraindicated in patients with a history of epiglottitis.

Choice B rationale:

Laryngeal edema refers to swelling of the larynx, which can also compromise the airway. While it is essential to monitor and manage laryngeal edema carefully, it is not an absolute contraindication for sterile suctioning. In some cases, suctioning may be necessary to maintain a patent airway, but it should be performed with caution and by experienced personnel.

Choice C rationale:

Difficulty clearing secretions is a common indication for sterile suctioning. Patients who have difficulty clearing their secretions may need suctioning to prevent the accumulation of mucus and maintain a clear airway. Therefore, this statement does not indicate a contraindication for the procedure.

Choice D rationale:

Using an artificial airway at night, such as a tracheostomy tube, indicates that the patient may require suctioning to maintain airway patency. While having an artificial airway increases the risk of infection and other complications, it is not a contraindication for sterile suctioning if clinically indicated.

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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

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?

Correct Answer is D

Explanation

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

Correct Answer is A

Explanation

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

(Online ATI/HESI question): A nurse is suctioning a patient with an artificial airway. Which of the following materials is preferred for suctioning catheters to reduce the risk of infection?

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

A client is undergoing sterile suctioning. Which interventions should the nurse implement during the suctioning procedure? Select all that apply.

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?

(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.

A nurse is preparing to perform sterile suctioning on a patient. What should the nurse do before suctioning?

A nurse is teaching infection control principles for sterile suctioning. Which measure is the most important to prevent cross-contamination during the procedure?