A nurse is preparing to perform nasotracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take?
Apply intermittent suction for 20 to 30 seconds.
Place the catheter in a location that is clean and dry for later use.
Hold the suction catheter with the clean, nondominant hand.
Use surgical asepsis when performing the procedure.
The Correct Answer is D
A. "Apply intermittent suction for 20 to 30 seconds." –
Suctioning should be applied intermittently for no more than 10 to 15 seconds to prevent hypoxia and mucosal damage.
B. "Place the catheter in a location that is clean and dry for later use." –
A suction catheter should not be reused once it has been used; it should be discarded after a single use to prevent infection.
C. "Hold the suction catheter with the clean, nondominant hand." –
The dominant hand should remain sterile and be used to control the suction catheter, while the nondominant hand is used to handle nonsterile equipment.
D. "Use surgical asepsis when performing the procedure." –
Nasotracheal suctioning is a sterile procedure because it involves direct access to the lower airway, requiring surgical asepsis to reduce the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Laboratory results Lab results are diagnostic data, not part of the health history. They are obtained separately through testing.
B. Physical examination findings The physical exam is a separate component of the assessment and is not included in the health history, which focuses on subjective data.
C. Health habits The health history includes subjective data provided by the client, such as dietary habits, exercise routine, smoking, alcohol use, sleep patterns, and medication use. This information helps the nurse understand the client’s lifestyle and risk factors.
D. Observed client behaviors While a nurse may take note of behaviors, the health history is based on the client’s self-reported information, not observations.
Correct Answer is A
Explanation
A. Consider gender and age when selecting an interpreter Cultural preferences may influence comfort and communication. For example, a client may feel more comfortable speaking with an interpreter of the same gender or age group.
B. Direct comments and questions to the interpreter The nurse should speak directly to the client, not the interpreter, to maintain engagement and respect.
C. Speak to the client in a loud voice Speaking louder does not improve comprehension and may come off as disrespectful. Clear, slow speech is more effective.
D. Ask a member of the client's family to serve as an interpreter Family members may omit or alter information and are not trained in medical terminology or confidentiality laws. A professional medical interpreter should be used.
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