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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Free Nursing Study Resources

Correct Answer is ["A","B"]

Explanation

Choice A: Cream is not allowed on a clear liquid diet because it contains fat and protein, which make it opaque.
Choice B:While plain gelatin is allowed, applesauce is not because it is a puréed/semi-solid food, not a clear liquid.
Choice C:Clear fruit juices without pulp (such as apple juice, cranberry juice, and white grape juice) are permitted.
Choice D:Broth or bouillon is considered a clear liquid, as long as it does not contain solid particles.
Choice E:Tea is a clear liquid, and sugar does not change its clarity.

Choice F:Ice pops made from clear liquids (such as fruit juice without pulp) are permitted.

A. Increase voice volume B. Stand next to the client when talking C. Ensure the light is on the face when talking D. Speak directly into one of the client's ears

Correct Answer is C

Explanation

This is because successful communication requires the eﬀorts of all people involved in a conversation. Even when the person with hearing loss utilizes hearing aids and active listening strategies, it is crucial that others involved in the communication process consistently use good communication strategies. One of these strategies is to face the hearing-impaired person directly, on the same level and in good light whenever possible. Position yourself so that the light is shining on the speaker's face, not in the eyes of the listener ¹.

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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?

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