Rebecca RPN is changing Mrs. Taurine's tracheostomy for the first time. Upon insertion of the suction catheter, Mrs. Taurine begins to cough. What is Rebecca's most appropriate action?
Discontinue suctioning and call the Doctor
Discontinue suctioning and check Mrs. Taurine's oxygen saturation
Pull back the suction catheter 1 inch and begin suctioning
Continue to insert catheter until she meets resistance and then begin suctioning
The Correct Answer is C
Rationale:
A. Calling the doctor is not necessary for a normal response like coughing during suctioning.
B. Checking oxygen saturation is important if distress occurs, but coughing alone is an expected response and does not require stopping the procedure.
C. Pulling back the suction catheter about 1 inch and then beginning suctioning is the correct action. Coughing indicates that the catheter has reached the carina or tracheal wall. Proper placement is slightly above this point to avoid trauma.
D. Advancing until resistance is met risks damaging the airway mucosa and should be avoided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Tracheal suctioning is the most appropriate intervention for a patient with a tracheostomy and thick, tenacious secretions. It directly clears the airway through the tracheostomy tube.
B. Nasotracheal suctioning is used for patients without a tracheostomy to access the lower airway through the nasal passage.
C. Orotracheal suctioning is also intended for patients without a tracheostomy and is more invasive.
D. Oropharyngeal suctioning clears secretions from the mouth and throat only, not the trachea, and is insufficient for maintaining a tracheostomy airway.
Correct Answer is C
Explanation
Rationale:
A. The prescriber is responsible for writing a clear and legible order, but the nurse should have clarified before administering.
B. The pharmacist helps verify medication orders but does not administer the medication.
C. The nurse is ultimately responsible for ensuring the order is clear and safe before administration. Administering a drug without clarification makes the nurse accountable for the error.
D. Errors are not considered “no fault”; accountability and corrective action are necessary to protect patient safety.
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