(Select all that apply). A nurse is suctioning a tracheostomy tube for a patient. Which of the following actions are correct during the suctioning process?
Apply continuous suction while inserting the catheter.
Rinse the catheter with sterile saline between each attempt.
Limit suctioning attempts to three per session.
Withdraw the catheter gently while applying suction.
Correct Answer : B,C,D,E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
Maintaining proper cuff pressure prevents pressure-related injuries and potential tracheoesophageal fistula (TEF) formation.
Choice B rationale:
Progressing to a deflated cuff or cuffless tube reduces the risk of TEF by minimizing pressure on the tracheal tissues.
Choice C rationale:
Tracheal dilation or surgical intervention may be necessary if TEF has already developed but is not a preventive measure.
Choice D rationale:
Using a small soft feeding tube instead of a nasogastric tube for tube feedings reduces the risk of trauma to the tracheal tissues and lowers the risk of TEF formation.
Choice E rationale:
Administering oxygen by mask may be necessary for oxygenation, but it is not specifically related to preventing tracheoesophageal fistula formation.
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