A nurse has received an order to suction a patient's endotracheal tube. Which action is most appropriate when performing this intervention?
Occlude the Y-port when inserting the catheter
Limit the application of suction to 20-30 seconds
Assist the client into a supine position in preparation for suctioning.
Use sterile saline to moisten the end of the suction catheter
The Correct Answer is B
A. Occluding the Y-port during insertion is not a standard practice and may impede proper suctioning.
B. Limiting the application of suction to 20-30 seconds helps prevent hypoxia and tissue damage.
C. Assisting the client into a supine position is not a standard practice for endotracheal tube suctioning.
D. Using sterile saline to moisten the end of the suction catheter may introduce unnecessary moisture into the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Urinary frequency is the need to void frequently.
B. Involuntary voiding refers to unintentional loss of urine.
C. Urinary retention is the inability to empty the bladder fully, often associated with an enlarged prostate.
D. Urinary incontinence is the involuntary loss of urine.
Correct Answer is D
Explanation
A. Laxative usage is more likely to cause diarrhea or loose stools rather than rectal pain from distended veins.
B. Paralytic ileus is characterized by a lack of bowel motility and is not associated with distention of veins in the rectum.
C. Diarrhea is unlikely to cause pain related to distention of rectal veins.
D. Hemorrhoids are swollen veins in the rectum and anus, causing pain and discomfort, especially during bowel movements.
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