(Select all that apply): A client requires sterile suctioning through a tracheostomy tube (TT). What steps should the nurse follow during the suctioning procedure? Select all that apply.
Limit each suction pass to no more than 10 seconds.
Apply suction while inserting the catheter.
Rotate the catheter between thumb and forefinger.
Rinse the catheter and tubing with saline after each suction pass.
Suction more than three times in a row for thorough cleaning.
Correct Answer : A,B,C,D
Choice A rationale:
The nurse should limit each suction pass to no more than 10 seconds to minimize the risk of tissue damage and hypoxia. Prolonged suctioning can cause trauma to the mucosa and lead to inadequate oxygenation.
Choice B rationale:
The nurse should apply suction while inserting the catheter to prevent the catheter from touching the airway walls before suction is initiated. This helps avoid stimulating the gag reflex and causing discomfort to the client.
Choice C rationale:
Rotating the catheter between the thumb and forefinger helps to facilitate even suctioning and prevent the catheter from adhering to the airway walls. It allows for effective removal of secretions without causing harm to the delicate tissues.
Choice D rationale:
After each suction pass, the nurse should rinse the catheter and tubing with saline to maintain its patency and prevent the buildup of secretions. This practice ensures that subsequent suctions are effective in clearing the airway.
Choice E rationale:
Suctioning more than three times in a row is not recommended because it can lead to hypoxia and tissue trauma. Frequent suctioning can reduce the oxygen levels in the airway and cause damage to the delicate tissues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
(Incorrect) Assuring the client that the procedure is entirely safe is not entirely accurate, as suctioning can carry some risks and discomfort.
Choice B rationale:
(Correct) This response acknowledges the client's concern about the suctioning procedure while providing a rationale for its importance, which is to maintain clear airways and prevent complications like airway blockage and respiratory distress.
Choice C rationale:
(Incorrect) Stating that there are no other options to remove secretions may not be true, and it does not address the client's concern effectively.
Choice D rationale:
(Incorrect) Promising to suction quickly may not address the client's worry and might compromise the effectiveness of the procedure, as thorough suctioning is necessary.
Correct Answer is A
Explanation
Choice A rationale:
The most crucial measure to prevent cross-contamination during sterile suctioning is the use of personal protective equipment (PPE). PPE, including gloves, gown, mask, and eye protection, creates a barrier between the healthcare provider and the patient's respiratory secretions, reducing the risk of infection transmission.
Choice B rationale:
Proper disposal of waste materials is important for infection control, but it is not the most critical measure to prevent cross-contamination during sterile suctioning. While proper waste disposal is necessary to reduce the spread of infections, using PPE is more directly related to preventing cross-contamination during the procedure.
Choice C rationale:
Environmental cleaning of the suction device is essential for infection control, but it is not the most important measure to prevent cross-contamination during sterile suctioning. The immediate and direct protection provided by PPE is more effective in reducing the risk of transmission during the procedure.
Choice D rationale:
Performing hand hygiene before and after the procedure is vital for infection control, but it is not the most crucial measure to prevent cross-contamination during sterile suctioning. While hand hygiene is essential for reducing the spread of infections, using PPE provides an additional layer of protection during the procedure.
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