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

Wait 1 min between 1 suctioning attempts

Apply intermittent suction for 30 seconds

Insert the catheter 10 cm (4 in.)

Apply suction while inserting the catheter.

Answer and Explanation

The Correct Answer is C

A) Wait 1 min between suctioning attempts: The nurse should wait 20 to 30 seconds between suctioning attempts, not a full minute. Waiting too long between attempts can cause the patient unnecessary distress. The goal is to allow for oxygenation and recovery of the airway in between suctioning attempts.

B) Apply intermittent suction for 30 seconds: Suctioning should be limited to 10 to 15 seconds at a time to prevent hypoxia and damage to the mucous membranes. Applying suction for 30 seconds could lead to complications such as hypoxia, mucosal trauma, and increased risk of infection.

C) Insert the catheter 10 cm (4 in.): This is the correct technique. For an adult client, the catheter should be inserted 10 cm (4 inches) into the airway. Inserting the catheter too far can cause trauma to the airway, while inserting it too shallow may not effectively clear secretions.

D) Apply suction while inserting the catheter: Suction should not be applied while inserting the catheter. Suctioning should only be applied while withdrawing the catheter, not while inserting it, to prevent mucosal trauma and to ensure effective clearance of secretions. Suctioning during insertion could damage the airway and increase discomfort for the client.

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Correct Answer is C

Explanation

A) Occasional small clots in the urine:
Occasional small clots can be expected after a transurethral resection of the prostate (TURP) due to the surgical trauma to the prostate and surrounding tissues. However, any change in the nature or frequency of clots, or if they become larger, should be reported, but small clots are not immediately concerning in the early postoperative period.

B) Urine output of 300 mL over 8 hr:
This urine output is within a reasonable range. While urine output may be initially monitored closely after TURP, a volume of 300 mL over 8 hours does not constitute a concerning finding. It may be less than expected, but it is not an emergency. The nurse should continue to monitor urine output, but this is not immediately concerning unless the client has a significantly reduced or absent output.

C) Dark red urine:
Dark red urine is a concerning finding as it may indicate excessive bleeding or hemorrhage, especially within the first 24 hours after TURP. While some initial hematuria (blood in the urine) is common, the urine should not remain dark red or worsen. This could indicate active bleeding or a clot obstructing the urinary flow, which requires immediate intervention and reporting to the healthcare provider to prevent complications.

D) Frequent urge to urinate:
A frequent urge to urinate is not an unusual finding following TURP, as the bladder may be irritated due to the catheter or residual inflammation from the surgery. While it is a discomforting symptom, it is typically not an immediate concern and often resolves as the healing process progresses. However, persistent or painful urination may require further evaluation.

A. Maintain a safe and private environment for the client B. Request a consult for case management C. Provide resources to the client for the local Alcoholics Anonymous chapter D. Contact children and youth services E. Provide resources for local support services F. Administer sexually transmitted infection prophylaxis

Correct Answer is ["A","B","E","F"]

Explanation

A. Maintain a safe and private environment for the client – Anticipated. Providing a secure and private setting helps support the client emotionally and ensures confidentiality during a sensitive situation.

B. Request a consult for case management – Anticipated. Case management can coordinate follow-up care, legal support, counseling, and additional resources for the client.

C. Provide resources to the client for the local Alcoholics Anonymous chapter – Contraindicated. There is no indication that the client has an alcohol use disorder. The focus should remain on addressing the sexual assault.

D. Contact children and youth services – Contraindicated. The client is a college student and an adult. There is no mention of minors being involved, so reporting to child protective services is unnecessary.

E. Provide resources for local support services – Anticipated. Connecting the client with crisis centers, advocacy groups, and counseling services is essential for emotional and psychological support.

F. Administer sexually transmitted infection prophylaxis – Anticipated. Post-exposure prophylaxis (PEP) for sexually transmitted infections (STIs), including gonorrhea, chlamydia, and HIV, should be administered to prevent potential infection.

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

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