A nurse is preparing to perform sterile suctioning for a patient with an endotracheal tube (ETT). What should the nurse do before suctioning?
Check the patient's blood pressure.
Place the patient in the supine position.
Insert the catheter without resistance.
Preoxygenate the patient with 100% oxygen.
The Correct Answer is D
Choice D rationale:
Before performing sterile suctioning on a patient with an endotracheal tube (ETT), the nurse should preoxygenate the patient with 100% oxygen. Suctioning can temporarily decrease oxygen levels in the airway, and preoxygenation helps prevent hypoxia during the procedure.
Choice A rationale:
Checking the patient's blood pressure is not directly related to the preparation for sterile suctioning. However, the nurse should monitor vital signs during and after the procedure.
Choice B rationale:
Placing the patient in the supine position is not a specific requirement for sterile suctioning. The nurse should position the patient appropriately for the procedure to ensure optimal access to the airway.
Choice C rationale:
Inserting the catheter without resistance is not a recommended action. The nurse should assess the patient's airway and ensure proper placement of the suctioning catheter to avoid causing injury or damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
(Correct) After sterile suctioning, it is essential to reposition the patient to a comfortable and safe position, ensuring proper alignment and support to prevent complications.
Choice B rationale:
(Incorrect) While documentation is crucial, ensuring the patient's safety and comfort should be the immediate priority after the procedure.
Choice C rationale:
(Incorrect) The nurse should not remove the catheter and tubing from the artificial airway immediately after suctioning, as it may still be needed for subsequent interventions.
Choice D rationale:
(Incorrect) Assessing the patient's response to suctioning is essential, but ensuring safety and repositioning take precedence immediately after the procedure.
Correct Answer is D
Explanation
Choice D rationale:
The nurse should respond by acknowledging the discomfort and pausing the procedure to reposition the nasopharyngeal tube. Repositioning can help alleviate the discomfort while ensuring the oxygenation needs are still met.
Choice A rationale:
Increasing the suction pressure may exacerbate the discomfort and cause further irritation to the nose and airway.
Choice B rationale:
Instructing the client to breathe through the mouth may not adequately address the discomfort and may not be feasible if the oxygenation is dependent on the nasopharyngeal tube.
Choice C rationale:
Although explaining the necessity of suctioning is important, it does not directly address the client's immediate discomfort. The priority is to address the client's comfort and safety during the procedure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.