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 A

Explanation

The correct answer is choicea. Obtain the client’s blood pressure in the other arm.

Choice A rationale:

Obtaining the client’s blood pressure in the other arm is crucial to avoid compromising the arteriovenous fistula. Measuring blood pressure in the arm with the fistula can damage the access site and impair its function.

Choice B rationale:

Encouraging the client to increase fluid intake is not appropriate for clients undergoing hemodialysis, as they often need to restrict fluid intake to prevent fluid overload.

Choice C rationale:

Reinforcing with the client to sleep on the side of the access site is incorrect. Clients should avoid sleeping on the arm with the fistula to prevent compression and potential damage to the access site.

Choice D rationale:

Obtaining the client’s weight is important for monitoring fluid balance, but it is not specific to the care of the arteriovenous fistula.

A. Administer aspirin if the client develops a fever. B. Initiate contact precautions for the client. C. Assign the client to a negative-pressure airflow room. D. Have visitors remain at least 0.91 m (3 feet. away from the client.

Correct Answer is C

Explanation

The correct answer is choicec. Assign the client to a negative-pressure airflow room.

Choice A rationale:

Administering aspirin to a client with varicella zoster is not recommended due to the risk of Reye’s syndrome, a serious condition that can cause swelling in the liver and brain.

Choice B rationale:

While contact precautions are important, varicella zoster also requires airborne precautions due to its highly contagious nature. This means that simply initiating contact precautions is not sufficient.

Choice C rationale:

Assigning the client to a negative-pressure airflow room is crucial because it helps contain the airborne virus and prevents it from spreading to other areas of the hospital.

Choice D rationale:

Having visitors remain at least 0.91 m (3 feet) away from the client is a good practice, but it is not sufficient on its own to prevent the spread of the virus. Airborne precautions, including a negative-pressure room, are necessary.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is scheduled for hemodialysis via an arteriovenous fistula in the arm. Which of the following actions should the nurse recommend?

Correct Answer is A

Explanation

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

Correct Answer is C

Explanation

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