(Select all that apply): A nurse is preparing to perform nasopharyngeal suctioning for a patient with a nasopharyngeal tube (NPT). What actions should the nurse take during the procedure? Select all that apply.
Insert the catheter until resistance is met.
Preoxygenate the patient with 100% oxygen.
Apply intermittent suction while inserting the catheter.
Limit each suction pass to no more than 15 seconds.
Rinse the catheter and tubing with saline after each suction pass.
Correct Answer : B,D,E
Choice A rationale:
The nurse should not insert the catheter until resistance is met during nasopharyngeal suctioning. This action could cause trauma to the nasal mucosa or other structures in the nasopharynx.
Choice B rationale:
Preoxygenating the patient with 100% oxygen is important before nasopharyngeal suctioning to prevent hypoxia during the procedure. Suctioning can temporarily decrease oxygen levels, so preoxygenation helps maintain adequate oxygenation.
Choice C rationale:
Applying intermittent suction while inserting the catheter is not recommended during nasopharyngeal suctioning. Continuous suction is preferred for effective removal of secretions.
Choice D rationale:
Limiting each suction pass to no more than 15 seconds is an essential practice during nasopharyngeal suctioning. Prolonged suctioning can cause hypoxia and discomfort for the patient.
Choice E 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not discard the used catheter and gloves into a regular trash bin because they were used in a sterile procedure, and improper disposal could lead to the risk of contamination and infection for both the patient and others.
Choice B rationale:
Although it is important to assess the patient's response to suctioning, including vital signs, this should not be the immediate next step after completing sterile suctioning. First, the nurse should ensure their own and the patient's safety by following proper infection control measures.
Choice C rationale:
After completing sterile suctioning, the nurse should perform hand hygiene to prevent the spread of infection and then don a new pair of sterile gloves before performing any other tasks or assessments. This step ensures that the nurse maintains a sterile field and minimizes the risk of introducing pathogens into the patient's airway.
Choice D rationale:
Increasing the suction pressure for one last pass is not necessary and may cause harm to the patient's airway. Proper suctioning technique involves limiting the suctioning time and pressure to avoid tissue damage and potential complications.
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