A nurse is performing sterile suctioning and observes the patient's oxygen saturation dropping below the normal range. Which statement by the nurse is appropriate?
"It's common for the oxygen saturation to drop during suctioning.".
"This is a normal response, and your oxygen levels will improve soon.".
"I will stop suctioning immediately and provide you with oxygen.".
"You should take slow deep breaths to increase your oxygen levels.".
The Correct Answer is C
Choice A rationale:
(Incorrect) Stating that it's common for oxygen saturation to drop during suctioning is not appropriate because a drop in oxygen saturation is an abnormal response that requires immediate intervention.
Choice B rationale:
(Incorrect) Telling the patient that a drop in oxygen levels is a normal response and will improve soon is incorrect and may lead to delay in addressing the potential respiratory distress.
Choice C rationale:
(Correct) This response is appropriate because the nurse should stop suctioning immediately if the patient's oxygen saturation drops below the normal range and provide supplemental oxygen to maintain adequate oxygenation.
Choice D rationale:
(Incorrect) Advising the patient to take slow deep breaths to increase oxygen levels may not be sufficient to address the oxygen saturation drop, which requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
Rinsing the catheter and tubing with saline after each suction pass is not a standard practice and is not necessary for sterile suctioning.
Choice B rationale:
Inserting the catheter into the artificial airway using sterile technique is crucial to maintain the integrity of the procedure and prevent infections.
Choice C rationale:
Limiting each suction pass to no more than 10 seconds helps to prevent complications such as hypoxia and tissue damage.
Choice D rationale:
Providing oral or nasal care after suctioning helps maintain the patient's airway, promote comfort, and prevent infections.
Choice E rationale:
Applying continuous suction while withdrawing the catheter is not recommended as it can cause trauma to the airway and should be avoided during sterile suctioning.
Correct Answer is D
Explanation
Choice D rationale:
Before performing sterile suctioning on a patient with an endotracheal tube (ETT), the nurse should preoxygenate the patient with 100% oxygen. Suctioning can temporarily decrease oxygen levels in the airway, and preoxygenation helps prevent hypoxia during the procedure.
Choice A rationale:
Checking the patient's blood pressure is not directly related to the preparation for sterile suctioning. However, the nurse should monitor vital signs during and after the procedure.
Choice B rationale:
Placing the patient in the supine position is not a specific requirement for sterile suctioning. The nurse should position the patient appropriately for the procedure to ensure optimal access to the airway.
Choice C rationale:
Inserting the catheter without resistance is not a recommended action. The nurse should assess the patient's airway and ensure proper placement of the suctioning catheter to avoid causing injury or damage.
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