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 C
Explanation
Choice C rationale:
The nurse should acknowledge the patient's anxiety and respond empathetically. Assuring the patient that the nurse will explain each step during the procedure can help alleviate anxiety. This approach promotes trust and helps the patient feel more in control, which is important for patient cooperation during the suctioning procedure.
Choice A rationale:
Telling the patient not to worry and that it won't take long may come across as dismissive and not address the patient's concerns adequately.
Choice B rationale:
Offering to postpone the procedure is an option, but the nurse should first attempt to address the patient's anxiety and provide reassurance. If the anxiety persists despite the explanation, postponing the procedure can be considered.
Choice D rationale:
Dismissing the patient's anxiety by stating that suctioning is routine may not effectively address the patient's feelings and may not be comforting.
Correct Answer is A
Explanation
Choice A rationale:
Donning personal protective equipment (PPE) is the priority action before performing sterile suctioning. This helps prevent the transmission of infection from patient to nurse and vice versa.
Choice B rationale:
Preoxygenating the patient with 100% oxygen is essential before nasopharyngeal suctioning, but the priority action is to ensure the nurse's safety by using PPE.
Choice C rationale:
Obtaining baseline data on vital signs and secretions is an important step, but it can be done after the nurse has ensured their safety with appropriate PPE.
Choice D rationale:
Inserting the catheter into the artificial airway using sterile technique is part of the procedure but should be preceded by wearing proper PPE to maintain a sterile environment.
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.