A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Check for secretion clearance.
Check the function of the suction catheter.
Don sterile gloves.
Adjust the suction to 120 to 150 mm Hg.
Insert the catheter without suction.
Apply intermittent suction while rotating the catheter
Hyperoxygenate the client.
The Correct Answer is B,C,D,G,E,F,A
Check the function of the suction catheter: Ensures the catheter is functioning properly before starting the procedure.
Don sterile gloves: Maintains asepsis during the suctioning procedure.
Adjust the suction to 120 to 150 mm Hg: Proper suction pressure prevents mucosal trauma.
Hyperoxygenate the client: Prevents hypoxia during the suctioning process.
Insert the catheter without suction: Prevents trauma to mucosa by reducing suction on insertion.
Apply intermittent suction while rotating the catheter: Effectively clears secretions while minimizing tissue damage.
Check for secretion clearance: Ensures the airway is clear and the procedure was effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A) Cleanse the mask or collar with soapy water every other day. The mask or collar should be cleansed at least once daily to prevent bacterial growth and maintain hygiene.
B) Post "no smoking" warning signs at home in a prominent location. This is essential to reduce the risk of fire hazards associated with oxygen therapy.
C) Make sure the straps on the mask are secure but not too tight. Properly adjusted straps ensure a secure fit without causing skin breakdown or discomfort.
D) Check the tops of his ears regularly for skin breakdown. Prolonged use of oxygen masks can cause pressure injuries on the ears, making regular checks necessary.
E) Apply petroleum jelly around and inside the nares. Petroleum-based products are flammable and should be avoided. Water-based moisturizers are safer alternatives.
Correct Answer is D
Explanation
A. Directly over the umbilicus: This position is too low and would not generate effective pressure on the diaphragm.
B. Directly over the sternum: Applying pressure here risks injury to the chest cavity without effectively relieving airway obstruction.
C. Between the umbilicus and the symphysis pubis: This position is too low and ineffective for compressing the diaphragm.
D. Halfway between the xiphoid process and the umbilicus: This is the correct hand placement for the Heimlich maneuver to produce effective inward and upward pressure, dislodging the obstruction.
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