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 C
Explanation
A. Bradypnea: Hypoxia typically leads to tachypnea as the body attempts to increase oxygen intake.
B. Pallor: While it can be a sign of poor perfusion, cyanosis is more closely associated with hypoxia.
C. Cyanosis: A late sign of severe hypoxia, indicating a lack of oxygen in the tissues.
D. Bradycardia: Hypoxia usually stimulates tachycardia as the body tries to compensate.
Correct Answer is B
Explanation
A. Removing any adhesive from the patient's skin with acetone: Acetone is highly flammable and should not be used near oxygen equipment.
B. Assessing equipment in room for frayed cords: Frayed cords can cause electrical sparks, which may ignite in an oxygen-rich environment.
C. Reducing humidification on the oxygen delivery device: Humidification is essential to prevent mucosal dryness; reducing it unnecessarily can cause airway irritation.
D. Using clothing of synthetic cloth for the patient: Synthetic materials generate static electricity, which can ignite in the presence of oxygen. Cotton clothing is preferred.
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