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 ["B","C","D"]

Explanation

B. Ensure two nurses confirm the information on the blood label: Before initiating a blood transfusion, two nurses must verify the client’s identity, blood type, and compatibility with the donor blood. This step is essential to prevent transfusion reactions due to mismatched blood.

C. Obtain a large-bore IV catheter: A large-bore IV catheter (18–20 gauge) is necessary to facilitate the transfusion of packed red blood cells (PRBCs). A smaller gauge may cause hemolysis or delay administration.

D. Witness the client signing a consent for transfusion: A blood transfusion is an invasive procedure requiring informed consent. The nurse ensures the client understands the risks, benefits, and potential complications before signing the consent form.

Incorrect Options:

A. Explain to the client that transfusion reactions are not serious: This is incorrect because transfusion reactions can range from mild allergic responses to life-threatening anaphylaxis or hemolytic reactions. The nurse should educate the client on symptoms to report, such as fever, chills, or dyspnea.

E. Ensure the transfusion tubing is flushed with dextrose 5% in water: Blood products should only be administered with 0.9% sodium chloride to prevent hemolysis. Using dextrose solutions can cause red blood cell aggregation and clot formation.

A. Offer the client several choices at mealtimes B. Remind the client of the day and time often C. Avoid discussing the client's fears D. Alternate daily caregivers.

Correct Answer is C

Explanation

A) "I get nervous when I'm in a large group": Social anxiety or nervousness in large groups is common, especially during adolescence. While it can indicate discomfort in social situations, it is not necessarily a warning sign of suicidal ideation.

B) "My partner and I had our first argument last night": Relationship conflicts are a normal part of adolescent development, and although they can cause emotional distress, a single argument does not typically indicate a risk for suicide. It’s important to assess the client’s overall emotional state and coping mechanisms, but this statement alone does not suggest suicidal thoughts.

C) "I am not interested in anything anymore.": This statement is a red flag for depression and potential suicidal ideation. A loss of interest or pleasure in activities that were once enjoyable (anhedonia) is a core symptom of depression, which can be a significant risk factor for suicide. This warrants further exploration and immediate attention from the nurse.

D) "I'm not sleeping much because of all the homework I have.": While lack of sleep can be a concern and may affect an adolescent’s overall health and well-being, it is more likely related to stress or academic pressure rather than suicidal thoughts. Sleep disturbances in adolescents are common, particularly when facing high academic expectations, but this is not an immediate sign of suicide risk.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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