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.
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Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
After providing perineal care and donning sterile gloves, the nurse should first lubricate the catheter tip followed by insert the catheter until urine flows.
Rationale:
- Lubricating the catheter tip ensures smooth insertion and minimizes discomfort or trauma to the urethra.
- Inserting the catheter until urine flows confirms proper placement before advancing slightly more to ensure complete drainage.
Correct Answer is C
Explanation
A. Prime the IV tubing with lactated Ringer's. Blood products should only be primed with 0.9% sodium chloride (normal saline) because other solutions (e.g., lactated Ringer's or dextrose solutions) can cause hemolysis.
B. Use a 24-gauge IV catheter for the transfusion. A 24-gauge catheter is too small for a blood transfusion and may cause hemolysis or slow infusion. A large-bore catheter (18–20 gauge) is recommended for optimal flow.
C. Ensure that the IV tubing has an in-line filter. An in-line filter helps remove clots and debris, reducing the risk of transfusion reactions.
D. Prepare to change the tubing at least every 2 hr. Blood tubing should typically be changed after 4 hours or after two units of blood, whichever comes first, to prevent bacterial contamination.
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