A nurse is caring for a client who has a new tracheostomy. Which of the following actions should the nurse take when suctioning the client's tracheostomy?
Set the suction source at 220 mm Hg.
Repeat suctioning as needed up to five times.
Hyperventilate the client with 100% oxygen before suctioning.
Suction for 20 seconds with each pass.
The Correct Answer is C
Rationale:
A. Set the suction source at 220 mm Hg: This pressure is excessively high and can damage tracheal mucosa. Recommended suction pressure for an adult tracheostomy is typically 80–120 mm Hg to minimize tissue trauma while effectively clearing secretions.
B. Repeat suctioning as needed up to five times: Frequent suction passes increase the risk of hypoxia and mucosal injury. Generally, suctioning should be limited to a maximum of three passes per session, allowing adequate recovery and reoxygenation between attempts.
C. Hyperventilate the client with 100% oxygen before suctioning: Preoxygenating helps prevent hypoxemia during suctioning by increasing oxygen reserves. This is a standard safety measure, especially in clients with artificial airways, to maintain oxygenation during the procedure.
D. Suction for 20 seconds with each pass: Prolonged suctioning increases the risk of hypoxia, arrhythmias, and airway trauma. Each suction pass should be limited to 10–15 seconds for adults to reduce complications and promote safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Instruct the client to flex the right knee every 30 min: After a femoral cardiac catheterization, the affected leg should remain straight to prevent bleeding or hematoma formation. Flexing the knee could disrupt hemostasis at the insertion site.
B. Assess the client's peripheral pulses every 15 min: Frequent monitoring of peripheral pulses ensures early detection of vascular complications such as thrombosis, occlusion, or impaired circulation in the affected limb.
C. Change the client's dressing 4 hr following the procedure: The initial dressing is typically left intact for several hours or until bleeding is controlled. Early dressing changes are unnecessary and may increase infection risk.
D. Elevate the head of the client's bed to 45°: Elevating the head of the bed can increase pressure on the femoral insertion site and risk bleeding. The client’s bed is usually kept flat or slightly elevated according to provider orders until hemostasis is confirmed.
Correct Answer is B
Explanation
A. Prospective audit: A prospective audit evaluates care before it is provided, focusing on planned interventions rather than outcomes after discharge. It is not used to assess post-care quality.
B. Outcome audit: Outcome audits measure the results of care, such as client recovery, complication rates, or satisfaction, after interventions have been completed. This type of audit is appropriate for gathering information about quality of care following discharge.
C. Structure audit: Structure audits assess the resources, staffing, and organizational infrastructure used to deliver care. They do not measure client outcomes or post-discharge quality.
D. Concurrent audit: Concurrent audits evaluate care while it is being provided, allowing immediate feedback and corrections. They are performed during hospitalization, not after discharge.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.