The nurse knows that the most effective method for suctioning a patient with a tracheostomy tube is which of the following.
Set suction regulator at 150 to 200 mm Hg.
Limit the length of suctioning to 10 to 15 seconds.
Liberally lubricate the end of the suction catheter with a water-soluble solution.
Apply suction while gently rotating and inserting the catheter.
The Correct Answer is B
Rationale:
A. Set suction regulator at 150 to 200 mmHg is too high; excessive suction pressure can damage mucosa and cause hypoxemia. The safe range is generally 80–120 mmHg for children and 100–150 mmHg for adults.
B. Limit the length of suctioning to 10 to 15 seconds is correct because prolonged suctioning increases the risk of hypoxia, bradycardia, and mucosal injury.
C. Liberally lubricate the end of the suction catheter with a water-soluble solution is not recommended; catheters are usually moistened with sterile saline if needed, not lubricated.
D. Apply suction while gently rotating and inserting the catheter is incorrect because suction should only be applied during withdrawal, not insertion, to prevent airway trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Ineffective airway clearance is the priority because a patient with a tracheostomy is at immediate risk for obstruction from secretions, which can compromise breathing and oxygenation.
B. Risk for infection is important but not the most urgent; airway patency takes precedence over potential complications.
C. Risk for skin breakdown is relevant to long-term care but not life-threatening in the immediate postoperative period.
D. Impaired gas exchange may occur if the airway is not cleared, but ensuring airway clearance comes first in the nursing priority hierarchy (Airway-Breathing-Circulation).
Correct Answer is D
Explanation
Rationale:
A. Sepsis usually develops over time with signs such as fever, chills, and hypotension, not acute fluid-related symptoms.
B. Anaphylaxis presents with airway swelling, rash, hypotension, and wheezing rather than fluid overload symptoms.
C. Myocardial infarction may cause chest pain, diaphoresis, and ECG changes, not typically linked directly to IV infusion rate.
D. Circulatory overload is the most likely cause. Rapid infusion (200 mL/hr in an elderly patient) can overwhelm cardiac function, leading to dyspnea, cough, tachycardia, and signs of fluid overload.
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