A nurse is caring for an adult client who requires nasopharyngeal suctioning. Which of the following actions should the nurse take?

Set the suction device to 120 mm Hg.

Apply suction to the catheter during insertion.

Have the client tuck his chin to his chest during suctioning.

Apply a petroleum-based lubricant to the catheter.

Answer and Explanation

The Correct Answer is A

A. Set the suction device to 120 mm Hg: For nasopharyngeal suctioning in adults, the suction pressure should typically be set between 100 and 120 mm Hg to prevent injury to the mucous membranes while effectively clearing secretions.

B. Apply suction to the catheter during insertion: Suction should not be applied during insertion of the catheter, as this can cause trauma to the mucous membranes. Suctioning should only occur when the catheter is in the appropriate position and being withdrawn.

C. Have the client tuck his chin to his chest during suctioning: The client should not tuck the chin to the chest during suctioning. Instead, the client should be asked to either cough or breathe normally. Tucking the chin may obstruct the airway and make suctioning difficult.

D. Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used as they can cause a fire hazard when oxygen is present. Instead, a water-soluble lubricant should be applied to the catheter if needed.

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Correct Answer is C

Explanation

A. "How often do you have trouble sleeping?": While this question might help assess general sleep issues, it doesn’t specifically address narcolepsy symptoms. Narcolepsy is characterized by excessive daytime sleepiness and episodes of sudden muscle weakness.

B. "Do you snore loudly?": Loud snoring is more commonly associated with sleep apnea rather than narcolepsy. Although both conditions can affect sleep quality, this question doesn’t directly relate to the hallmark symptoms of narcolepsy.

C. "Do you ever suddenly lose muscle control?": Sudden loss of muscle control, or cataplexy, is a key symptom of narcolepsy. Cataplexy occurs when a person experiences sudden muscle weakness or paralysis in response to strong emotions, such as laughter or surprise.

D. "Do you wake up with headaches?": Waking up with headaches could be related to sleep disorders such as sleep apnea or tension headaches, but it is not a defining feature of narcolepsy. The nurse should focus on symptoms directly related to narcolepsy.

A. Holds linens close to the body B. Shakes soiled linens before placing them in the hamper C. Puts unneeded clean linens in the hamper D. Places soiled linens on the floor

Correct Answer is A

Explanation

A. Holds linens close to the body: Holding linens close to the body reduces the risk of contamination and ensures that the linens do not touch potentially unclean surfaces. This practice helps maintain medical asepsis by preventing the spread of microorganisms.

B. Shakes soiled linens before placing them in the hamper: Shaking soiled linens can cause microorganisms to become airborne and spread. To maintain asepsis, linens should be handled gently and placed directly into the hamper without shaking.

C. Puts unneeded clean linens in the hamper: Clean linens should not be placed in the hamper as they could become contaminated. Clean linens should be stored in a clean area to maintain their aseptic state until needed.

D. Places soiled linens on the floor: Placing soiled linens on the floor introduces the risk of contamination, as the floor is not considered a clean surface. Soiled linens should be placed directly into a designated container to maintain medical asepsis.

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A nurse is caring for an adult client who requires nasopharyngeal suctioning. Which of the following actions should the nurse take?

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