(Select all that apply). A nurse is gathering equipment for suctioning a tracheostomy tube. Which of the following items should the nurse include in the setup?
Sterile gloves.
Sterile water or saline.
Pulse oximeter.
Sphygmomanometer.
Correct Answer : B,E
Choice A rationale:
Sterile gloves are essential for aseptic technique during tracheostomy suctioning to prevent the introduction of infection. However, they are not included in the setup, as they are worn by the nurse performing the procedure.
Choice B rationale:
Sterile water or saline is necessary for suctioning to moisten the suction catheter and facilitate the removal of secretions without causing trauma to the airway. Therefore, it should be included in the setup.
Choice C rationale:
A pulse oximeter is used to monitor the patient's oxygen saturation and is not directly related to tracheostomy suctioning. While continuous monitoring of oxygen saturation is essential during and after the procedure, it is not a part of the setup.
Choice D rationale:
A sphygmomanometer is used to measure blood pressure and is unrelated to tracheostomy suctioning. It is not required for this procedure.
Choice E rationale:
A non-sterile towel is used to protect the patient's clothing and bed linens from any secretions or spills during the suctioning procedure. It should be included in the setup to maintain cleanliness and prevent contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
Applying continuous suction while inserting the catheter can cause trauma to the tracheal mucosa and increase the risk of bleeding and infection.
Choice B rationale:
Rinsing the catheter with sterile saline between each suctioning attempt helps maintain aseptic technique, preventing the introduction of microorganisms into the airway.
Choice C rationale:
Limiting suctioning attempts to three per session reduces the risk of hypoxia and mucosal damage, ensuring adequate oxygenation and preventing complications.
Choice D rationale:
Withdrawing the catheter gently while applying suction prevents damage to the tracheal walls and minimizes the risk of bleeding.
Choice E rationale:
Hyperoxygenating the patient before and after suctioning helps prevent hypoxemia during the procedure, reducing the risk of complications and ensuring adequate oxygenation.
Correct Answer is B
Explanation
Choice A rationale:
Waiting for at least 10 seconds between each suctioning attempt may not provide sufficient time for the patient's oxygenation to stabilize. This short duration might not allow the patient's oxygen levels to return to an adequate baseline, leading to potential hypoxia during subsequent suctioning attempts.
Choice B rationale:
Waiting for at least 30 seconds between suctioning attempts allows more time for the patient's oxygen levels to recover. This duration strikes a balance between preventing hypoxia and removing secretions effectively. It also helps minimize the risk of complications associated with frequent or rapid suctioning.
Choice C rationale:
Waiting for at least 1 minute between suctioning attempts might be too long, especially if the patient is experiencing respiratory distress or has excessive secretions. Delaying suctioning for this duration could lead to an accumulation of secretions, potentially compromising the airway and causing distress for the patient.
Choice D rationale:
Waiting for at least 3 minutes between suctioning attempts is too long and not clinically appropriate. This extended time may lead to increased secretion buildup and potential airway obstruction, especially in patients with excessive secretions or those who are critically ill.
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