A nurse is nasopharyngeal suctioning an adult patient to remove thick secretions. The nurse will:
use a 14-Fr catheter
use suction pressure between 120 and 160 mm Hg
use an 8-Fr catheter
use the catheter to suction the mouth and nasopharynx
The Correct Answer is A
A. Use a 14-Fr catheter: This is the appropriate size for suctioning an adult to effectively remove thick secretions.
B. Use suction pressure between 120 and 160 mm Hg: This pressure is too high and may cause mucosal damage; 100 to 120 mm Hg is recommended for adults.
C. Use an 8-Fr catheter: This size is too small for effectively suctioning thick secretions in adults.
D. Use the catheter to suction the mouth and nasopharynx: Suctioning the mouth first contaminates the catheter, increasing the risk of infection in the nasopharynx.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bradypnea: Hypoxia typically leads to tachypnea as the body attempts to increase oxygen intake.
B. Pallor: While it can be a sign of poor perfusion, cyanosis is more closely associated with hypoxia.
C. Cyanosis: A late sign of severe hypoxia, indicating a lack of oxygen in the tissues.
D. Bradycardia: Hypoxia usually stimulates tachycardia as the body tries to compensate.
Correct Answer is A
Explanation
A. Start slowly and increase volume over several sessions: Gradually increasing lung volume improves compliance and helps clients build confidence with the device.
B. Be much more vigorous in increasing increments: Rapid or forceful attempts can cause hyperventilation or dizziness and are not recommended.
C. Do regular deep-breathing exercises instead: Deep breathing can be helpful but does not replace the targeted lung expansion benefits of the incentive spirometer.
D. Use another device because this one might be faulty: Device failure is rare; user education is usually more effective.
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