A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?
Apply intermittent suction for 30 seconds.
Insert the catheter 10 cm (4 in).
Apply suction while inserting the catheter.
Wait 1 min between suctioning attempts.
The Correct Answer is D
Waiting 1 minute between suctioning attempts allows the client to recover and ensures that the procedure is not overly invasive. It also helps to prevent the client from becoming hypoxic.
The distance that the nasopharyngeal catheter should be inserted varies from person to person and therefore 10 cm is not standard.
During nasopharyngeal suctioning, the nurse should apply suction intermittently while withdrawing the catheter, not during insertion. Applying suction during insertion can cause tissue damage and increase the risk of trauma.
The nurse should also apply intermittent suction for no longer than 15 seconds to prevent hypoxia and damage to the mucosal lining. Suctioning for an extended period can cause discomfort and harm to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
A. Inform the client that an advance directive discontinues further care.This statement is incorrect. An advance directive does not discontinue further care but outlines the client's preferences for medical treatment if they become unable to communicate their wishes.
B. Initiate a power of attorney for health care documents.This is not the nurse's responsibility. Initiating a power of attorney for health care documents typically involves legal consultation, and the client should be referred to appropriate resources.
C. Document that the provider discussed do-not-resuscitate status with the client.This is correct. The nurse should document that the provider has discussed DNR (Do Not Resuscitate) status with the client, ensuring that the discussion and decision are clearly recorded in the medical record.
D. Provide the client with written information about advance directives.This is correct. The nurse is responsible for providing the client with written information about advance directives, ensuring the client understands their rights and options.
E. Communicate advance directives status via the medical record and shift report.This is correct. The nurse must ensure that the client's advance directive status is clearly communicated in the medical record and during shift reports to ensure continuity of care.
F. Instruct the client that an advance directive is a legal document and must be honored by care providers.This is correct. The nurse should inform the client that an advance directive is a legal document that healthcare providers are required to honor, according to the client's wishes.
Correct Answer is B
Explanation
Giving the client the opportunity to participate in decision-making regarding the timing of treatments and procedures respects their autonomy and allows them to have some control over their care.
Be honest with the client about the prognosis: By providing accurate and honest information, the nurse respects the client's right to know and be involved in decision-making regarding their healthcare.
Provide privacy during client care procedures: Respecting the client's privacy during care procedures allows them to maintain a sense of dignity and control over their body.
Administer pain medication on a routine schedule: Ensuring that pain medication is provided on a routine schedule allows the client to have control over their pain management and helps maintain their comfort and quality of life
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