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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) "The headaches should decrease as you get used to the medication.": This statement is correct. A common side effect of isosorbide dinitrate is headaches, as the medication works by dilating blood vessels, which can cause a drop in blood pressure. These headaches typically occur when the medication starts, but they often decrease over time as the body adjusts to the drug. The nurse should reassure the client that this side effect is generally temporary.
B) "You should take the medication on an empty stomach to prevent a headache.": This statement is incorrect. While taking certain medications on an empty stomach may affect their absorption, isosorbide dinitrate is typically not recommended to be taken on an empty stomach to avoid headaches. In fact, it is more common for people to take it with food if it causes gastrointestinal discomfort, but this is not directly related to preventing headaches.
C) "You can discontinue the medication until the headache goes away.": This statement is incorrect. The client should not discontinue the medication without consulting the healthcare provider. Abruptly stopping isosorbide dinitrate can lead to withdrawal symptoms and potentially worsen the client's condition. The nurse should encourage the client to talk to their provider if the headache becomes unbearable or persistent, but not to stop the medication without guidance.
D) "Swallow the tablet whole to minimize your headaches.": This statement is incorrect. Isosorbide dinitrate in chewable form is designed to be chewed, as this method of administration helps the drug be absorbed more quickly and effectively. Swallowing the tablet whole would not address the issue of headaches and could affect how the medication works.
Correct Answer is B
Explanation
A) The client’s vital signs are checked every 8 hr: While vital signs are an important aspect of the client's health, this information is routine and doesn't provide new insights that would impact the overall plan of care during an interprofessional team meeting. It’s important to focus on changes in the client’s condition or specific concerns that require collaboration.
B) The client has developed difficulty ambulating: This is critical information to share during the interprofessional team meeting because it may require input from physical therapists, occupational therapists, or other specialists. Difficulty ambulating can indicate a need for reassessment of the client's mobility plan, and other team members need to be informed to develop appropriate interventions.
C) The client has state-sponsored health insurance: While the client’s insurance status is relevant for financial and discharge planning, it is not directly related to the clinical management or care coordination that would be discussed in an interprofessional team meeting. The focus should be on the client’s clinical condition and needs.
D) The client's next dressing change is scheduled in 4 hr: Although the dressing change is important for continuity of care, this is more of a task-related detail rather than critical clinical information that requires interprofessional discussion. The focus in a team meeting should be on the client's progress, challenges, and needs, not just routine care tasks.
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