The nurse provides care for a client diagnosed with pneumonia. The client is unable to expectorate respiratory secretions. The nurse suctions the client's nasopharyngeal airway. When is suctioning technique correct?

Advances catheter 2-3 inches (5 to 7.6 cm).

Applies suction intermittently for 20 seconds.

Moistens catheter prior to insertion.

Uses non-dominant hand to manipulate catheter.

Answer and Explanation

The Correct Answer is C

When suctioning a client's nasopharyngeal airway, the nurse should moisten the catheter with sterile saline or water-soluble lubricant prior to insertion. This helps to decrease discomfort and trauma to the client's nasal mucosa.

Advancing the catheter 2-3 inches (5 to 7.6 cm) (a) is not correct because it can cause injury to the client's airway or trachea. The catheter should only be inserted to a distance equal to the distance from the nose to the earlobe (about 6 to 8 inches or 15 to 20 cm).

Applying suction intermittently for 20 seconds (b) is not correct because it can cause hypoxia and trauma to the client's airway. The suction should be applied continuously while withdrawing the catheter, for no more than 10 seconds.

Using the non-dominant hand to manipulate the catheter (d) is not correct because it can cause the catheter to become contaminated with the nurse's non-sterile hand. The dominant hand should be used to manipulate the catheter while maintaining sterile technique.

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Correct Answer is C

Explanation

Before applying anti-embolism stockings, the nurse should ask the client to lie supine in bed for 15 minutes. This is because anti-embolism stockings should be applied with the client in a supine position ¹. This helps to promote blood return to the heart and decrease the risk of blood clots ¹.

A. Wear sterile gloves to pack the wound. B. Clean the skin around the wound with non-sterile 4x4 gauze. C. Don an eye shield before irrigating the wound. D. Use alcohol-based hand sanitizer between glove changes. E. Pour sterile normal saline into a sterile irrigation tray. F. Obtain a wound culture before the wound bed is irrigated. G. Cover the irrigated packing with an ABD pad. H. Assess pain prior to starting the procedure. I. Wear sterile gloves to remove the old dressing.

Correct Answer is ["A","C","E","F","G","I"]

Explanation

a) It is important to wear sterile gloves when packing the wound to prevent the introduction of new bacteria into the wound.
c) Donning an eye shield protects the nurse from splash-back or aerosolized particles during irrigation.
e) Sterile normal saline should be used for irrigation to prevent introducing new bacteria to the wound. It should be poured into a sterile irrigation tray.
f) A wound culture should be obtained before the wound bed is irrigated to prevent diluting the specimen with irrigation solution.
g) After irrigating the wound and packing it with sterile gauze, the packing should be covered with an ABD pad to protect the wound and prevent contamination.
h) Assessing pain prior to starting the procedure is important to establish a baseline for pain management and to monitor the client's response to the procedure.
i) Sterile gloves should be worn when removing the old dressing to prevent introducing new bacteria to the wound.
b) Cleaning the skin around the wound with non-sterile gauze is not appropriate as it can introduce new bacteria to the wound.
d) Alcohol-based hand sanitizer is not a substitute for hand washing and should not be used between glove changes as it does not eﬀectively remove all bacteria from the hands.

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The nurse provides care for a client diagnosed with pneumonia. The client is unable to expectorate respiratory secretions. The nurse suctions the client's nasopharyngeal airway. When is suctioning technique correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client recovering from surgery sits in a chair for breakfast. Which action does the nurse take before applying newly prescribed anti-embolism stockings to the client's lower extremities?

Correct Answer is C

Explanation

Correct Answer is ["A","C","E","F","G","I"]

Explanation

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