An RN is observing a nursing student who is performing closed suctioning on a hospitalized patient with an endotracheal (ET) tube in place. Which actions by the student require the RN to intervene? Select all that apply.
Applies suction while inserting the catheter.
Adjusts wall suction to 100-120 mm Hg.
Adds air to the ET tube and slightly deflates the cuff.
Hyperoxygenates the patient with 100
Inserts the catheter until resistance is met.
Correct Answer : A,C,E
Choice A rationale
Suction should never be applied during the insertion of the catheter because it can cause mucosal trauma, deplete the patient's oxygen reserves, and increase the risk of atelectasis. The catheter should be inserted with the suction turned off. Suction is only applied intermittently or continuously while withdrawing the catheter. The nurse must intervene to prevent injury to the tracheal wall and to ensure the patient maintains adequate oxygenation during the procedure.
Choice B rationale
Adjusting the wall suction to a range of 100 to 120 mm Hg is an appropriate and standard action for an adult patient. This level of pressure is sufficient to remove secretions without causing excessive damage to the delicate tracheal mucosa or causing significant lung collapse. Since this is a correct action, the RN does not need to intervene. The goal is to use the lowest effective pressure to clear the airway effectively.
Choice C rationale
Adding air to the tube or deflating the cuff during suctioning is an incorrect and dangerous practice. The cuff must remain inflated to provide a seal for mechanical ventilation and to protect the airway from the aspiration of subglottic secretions. Deflating the cuff could cause the patient to lose tidal volume or inhale oral contaminants. The RN must intervene to ensure the cuff integrity is maintained and the patient's ventilation is not compromised.
Choice D rationale
Hyperoxygenating the patient with 100 percent oxygen for at least 30 to 60 seconds before suctioning is a standard nursing intervention. Suctioning inherently removes oxygen from the airways along with secretions, which can lead to hypoxemia and cardiac arrhythmias. By providing extra oxygen beforehand, the student helps maintain the patient's oxygen saturation levels. This is a correct clinical behavior, so no intervention from the RN is required in this instance.
Choice E rationale
Inserting the catheter until resistance is met can cause significant trauma to the carina and trigger a violent cough reflex or bronchospasm. Current evidence-based guidelines recommend "shallow suctioning," where the catheter is inserted only to a predetermined length or just past the end of the ET tube. The RN should intervene to teach the student to avoid hitting the carina, thereby reducing the risk of tissue damage and patient discomfort during the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8"]
Explanation
Step 1 is 80 kg × 5 mg/kg = 400 mg.
Step 2 is 400 mg ÷ (150 mg ÷ 3 mL) = 8 mL. Final calculated answer is 8 mL.
Correct Answer is A
Explanation
Choice A rationale
The mixed venous oxygen saturation, or SvO2, represents the balance between oxygen delivery and oxygen consumption by the tissues. A normal SvO2 value ranges from 60.
Choice B rationale
Hypoxic respiratory failure occurs when the arterial partial pressure of oxygen is less than 60 mmHg. In such states, oxygen delivery to the tissues is severely compromised. This leads to increased oxygen extraction at the cellular level to compensate for the low supply. Consequently, the SvO2 would drop significantly below the normal 60.
Choice C rationale
When oxygen supply decreases or metabolic demand increases, such as during fever, shivering, or seizures, the tissues must extract more oxygen from the passing blood. This compensatory mechanism results in a lower amount of oxygen remaining in the venous blood. Therefore, if there were an imbalance where demand exceeded supply, the SvO2 value would be expected to fall below the normal range of 60.
Choice D rationale
Hypercapnic respiratory failure is characterized by an inability to eliminate carbon dioxide, leading to a partial pressure of arterial carbon dioxide greater than 45 mmHg. While this affects acid-base balance and respiratory drive, it does not directly define the SvO2 value. SvO2 specifically measures oxygenation balance. While severe hypercapnia can eventually lead to poor oxygenation, a normal SvO2 of 70.
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