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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Meningococcal immunization typically includes different schedules and doses; stating three doses before kindergarten is not accurate.
B. Correct. The rotavirus vaccine is administered orally to infants.
C. Feeding restrictions before immunizations are not routinely required for infants.
D. While some mild fever after immunizations is possible, the statement suggests an expectation of a high fever for 24 hours, which is not accurate.

A. Tell the APS to stop the conversation. B. Document the event in the client's progress notes. C. Inform the client of the APs' actions. D. Submit an incident report to the risk manager.

Correct Answer is A

Explanation

A. Correct. Overhearing private client information being discussed by staff members violates the client's right to privacy and confidentiality. The nurse should address the situation immediately and instruct the assistive personnel to stop the conversation.
B. Incorrect. While documenting the event in the client's progress notes may be necessary, addressing the inappropriate behavior of the assistive personnel takes precedence.
C. Incorrect. Informing the client about the conversation is not necessary and may further compromise the client's sense of privacy.
D. Incorrect. Submitting an incident report to the risk manager might be necessary, but the immediate action should be to stop the conversation and address the breach of confidentiality.

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A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

Nursing Test Bank

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