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","C","D"]

Explanation

These are all important steps in rendering prescribed wound care for a child with an abdominal wound. Measuring the size of the wound helps to track healing progress. Working outward from the incision and wiping from a clean area to a less clean area helps to prevent infection.

A. Bradycardia B. Hypertension C. Tachypnea D. Pyrexia

Correct Answer is A

Explanation

A rectal temperature should not be taken if the client has bradycardia because stimulation of the vagus nerve during the insertion of the rectal thermometer can result in a further decrease in heart rate. Hypertension, tachypnea, and pyrexia are not contraindications for taking a rectal temperature.

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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

The nurse provides care for a child with an abdominal wound. The wound edges are approximated. Which does the nurse include when rendering the prescribed wound care to this child? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

The nurse delegated vital signs for a group of patients to the unlicensed assistive personnel (UAP). Which client condition would prohibit having a rectal temperature taken by the UAP?

Correct Answer is A

Explanation

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