The nurse is setting up the environment for tracheal suction on a newly postoperative tracheostomy patient. Which action(s) should the nurse perform? (Select 4 correct answers)
Perform suction with sterile supplies.
Auscultate lungs for retained secretions.
Don clean gloves and lift out catheter and connect to suction.
Wash hands and open sterile suction kit.
Inform the patient about the procedure.
Correct Answer : A,B,D,E
A. Perform suction with sterile supplies: Sterile technique is essential when suctioning a tracheostomy to prevent introducing pathogens into the lower airway. Sterile supplies and gloves help reduce the risk of infection in this direct airway access point.
B. Auscultate lungs for retained secretions: Before suctioning, the nurse should assess for signs that suctioning is needed, such as abnormal breath sounds (e.g., crackles, rhonchi) that indicate secretion buildup in the airways.
C. Don clean gloves and lift out catheter and connect to suction: Clean gloves are insufficient for the suctioning procedure. This is an invasive technique involving direct access to the lower airway, requiring sterile gloves and equipment to prevent infection.
D. Wash hands and open sterile suction kit: Hand hygiene is a fundamental part of infection control. Opening the sterile suction kit properly maintains the sterility of equipment needed for the procedure.
E. Inform the patient about the procedure: Providing a brief explanation prepares the patient, reduces anxiety, and promotes cooperation. Even if the patient is nonverbal, communication is part of professional and ethical nursing care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Initiate and maintain supplemental oxygen as prescribed: Supplemental oxygen helps improve oxygenation but does not directly address the underlying issue of retained secretions. Oxygen delivery is important, but secretion removal is the priority when the airway is obstructed.
B. Plan activities with rest periods to conserve oxygen needs: While energy conservation is useful for managing oxygen demand in alert clients, it does not apply to an unresponsive client. Additionally, it does not assist with clearing the airway or managing retained secretions.
C. Provide nasotracheal suctioning as needed to remove secretions: Suctioning is the most appropriate intervention for an unresponsive client with retained secretions, as they are unable to cough or clear their own airway. This intervention directly supports airway clearance and improves ventilation.
D. Monitor oxygenation (the oxygen saturation [SaO2]) during activity: Monitoring oxygen saturation is helpful for evaluating respiratory status, but this intervention does not address the immediate problem of retained secretions compromising airway clearance.
Correct Answer is A
Explanation
A. A possible airway obstruction: The tripod positionis a classic sign of epiglottitis and indicates the child is attempting to maximize airway patency. This posture helps keep the airway open and suggests significant upper airway obstruction, requiring immediate intervention.
B. The presence of pain: While children with epiglottitis often experience throat pain, this posture is not primarily used to relieve pain. It is associated with efforts to ease breathing and maintain airflow in the face of an obstructed or narrowed airway.
C. Extreme fatigue: Fatigue may occur in respiratory illnesses, but the tripod position is an active posture that requires muscle engagement. It is not a typical sign of fatigue and more accurately reflects respiratory distress and airway compromise.
D. Dehydration: Dehydration may be present in epiglottitis due to poor oral intake, but it does not cause the child to assume the tripod position. The posture is a compensatory mechanism for airway obstruction, not a direct result of fluid imbalance.
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