During sterile suctioning, the nurse observes the patient experiencing bronchospasm and increased intracranial pressure. What should be the nurse's immediate action?
Continue suctioning to clear the airway completely.
Adjust the pressure on the suction device.
Stop suctioning immediately and provide appropriate interventions.
Increase the suction pass time to remove more secretions.
The Correct Answer is C
Choice A rationale:
Continuing suctioning when the patient is experiencing bronchospasm and increased intracranial pressure can worsen their condition and potentially lead to further complications. It is not appropriate to continue suctioning in this situation.
Choice B rationale:
Adjusting the pressure on the suction device may not be sufficient to address the patient's current condition. Stopping suctioning and providing appropriate interventions are more crucial in this situation.
Choice C rationale:
Stopping suctioning immediately is the most appropriate action when the patient experiences bronchospasm and increased intracranial pressure. The nurse should assess the patient's airway, administer bronchodilators or other prescribed treatments as needed, and seek medical assistance if necessary.
Choice D rationale:
Increasing the suction pass time is not recommended as it can exacerbate the patient's condition and lead to complications. The focus should be on stopping suctioning and providing appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale:
The nurse should not rotate the catheter between the thumb and forefinger during suctioning. This action could cause trauma to the airway.
Choice B rationale:
Limiting each suction pass to no more than 10 seconds is an essential practice during sterile suctioning. Prolonged suctioning can lead to hypoxia and potential complications.
Choice C rationale:
Rinsing the catheter and tubing with saline after each suction pass helps maintain patency and prevent the accumulation of secretions, ensuring effective suctioning during the procedure.
Choice D rationale:
Applying continuous suction while inserting the catheter is not recommended during sterile suctioning. Intermittent suction is preferred for safety and effectiveness.
Choice E rationale:
Providing encouragement and support to the client throughout the procedure is crucial for their comfort and cooperation. Suctioning can be uncomfortable, and the client may need reassurance during the process.
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.