A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Don sterile gloves.

Turn on the suction and set the pressure.

Insert the catheter during the client's inspiration.

Apply suction while rotating the catheter.

Rinse the catheter to remove secretions.

Answer and Explanation

The Correct Answer is A,B,C,D,E

A.   The nurse should begin by donning sterile gloves to maintain a sterile field.
B.   The suction machine should be turned on, and the pressure should be set before starting the suctioning.
C.   The catheter should be inserted during the client’s inspiration to minimize discomfort and maximize
effectiveness.
D.   Suction should be applied while rotating the catheter to prevent tissue damage and to clear secretions effectively.
E.   After suctioning, the catheter should be rinsed to remove any remaining secretions.

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Correct Answer is B

Explanation

A. Offering clear liquids should typically occur 6 hours or later postoperatively; in the first few hours, the focus is on monitoring and pain management.
B. Administering analgesics on a scheduled basis ensures consistent pain control and helps prevent unnecessary discomfort.
C. Applying a warm compress is not appropriate in the early postoperative period and may risk increased bleeding.
D. Giving cromolyn nebulized solution is unrelated to appendectomy recovery and is not part of standard postoperative care.

A. "How long have you been hearing the voices?" B. "I realize the voices are real to you, but I don't hear anything." C. "What are the voices telling you?" D. "Have you taken your medication today?"

Correct Answer is C

Explanation

A. While it is important to assess the duration of symptoms, it is more important to understand the content and context of the voices to determine potential risks.
B. Acknowledging that the voices are real to the client, while not hearing them, shows empathy and avoids invalidating the client's experience.
C. Understanding what the voices are saying helps assess the potential for harm and allows for appropriate intervention.
D. While checking on medication adherence is important, it does not address the immediate concern of what the voices may be telling the client.

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A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?

Correct Answer is C

Explanation

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