A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?
Insert the catheter 10 cm (4 in..
Apply suction while inserting the catheter.
Apply intermittent suction for 30 seconds.
Wait 1 min between suctioning attempts.
The Correct Answer is D
A. In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.
B. Suction should not be applied while inserting the catheter, as it could cause trauma to the mucosa and increase discomfort. Suction should only be applied while withdrawing the catheter, and it should be done intermittently to avoid injury and reduce the risk of hypoxia.
C. Suctioning should not exceed 10-15 seconds at a time to prevent hypoxia and other complications. Prolonged suctioning can lead to oxygen depletion and potential respiratory distress in the client.
D. Waiting at least 1 minute between suctioning attempts allows the client to recover and helps maintain adequate oxygenation. This pause is essential to prevent hypoxia and to ensure the client has time to breathe normally before the next suctioning attempt.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
Taping the tube to the child's cheek is not typically done as it can cause discomfort and skin irritation. The tube should be secured with a stabilization device or a specialized dressing designed for gastrostomy tube care.
Applying a skin barrier protectant around the gastrostomy site is a good practice. It helps protect the skin from irritation, breakdown, and leakage of gastric contents, which can cause skin excoriation. This helps maintain the integrity of the skin around the site.
Applying water-soluble lubricant to the site is not necessary for routine site care. Lubrication is typically used when inserting or removing the tube, but it is not part of routine site care.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
Given the client's symptoms (productive cough, blood-tinged sputum, fatigue, night sweats, low-grade fever, weight loss, and recent travel to South Africa), there is a suspicion of tuberculosis (TB). The Mantoux test (a skin test for TB) and a chest X-ray are appropriate diagnostic tools to evaluate for TB.
A. a nasopharyngeal swab: This test is used to detect respiratory infections, but the client's symptoms and history do not specifically indicate the need for this test.
B. A pulmonary function test: While this test assesses lung function, it may not be the initial choice for evaluating the presented symptoms and history.
C. A chest x-ray
Rationale: Given the client's symptoms of cough, fatigue, night sweats, low-grade fever, and blood-tinged sputum, a chest x-ray is indicated to assess the condition of the lungs and potential underlying respiratory issues.
D. blood cultures
Rationale: The client's symptoms, including fever, could indicate an underlying infection. Blood cultures are used to identify potential bacterial or fungal infections in the bloodstream, but this is not likely for this patient
E. a Mantoux test
Rationale: The client's recent travel history, cough, and weight loss may prompt consideration of a tuberculosis (TB) infection. A Mantoux test is a common initial screening tool for TB exposure.
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