A home health nurse is teaching about endotracheal suctioning. Which of the following information should the nurse include in the teaching?
Allow the client to rest for 10 to 15 seconds after each suctioning attempt.
Set the suction pressure to 110 mm Hg
Apply suction for less than 10 seconds.
Apply suction when inserting the catheter.
Correct Answer : A,C
A) Allow the client to rest for 10 to 15 seconds after each suctioning attempt: Allowing the client to rest between suctioning attempts helps to minimize hypoxemia and reduces the risk of trauma to the airway mucosa. It also allows the client to recover from the physiological stress of suctioning before initiating another attempt.
C) Apply suction for less than 10 seconds: Prolonged suctioning can lead to hypoxemia and tissue trauma. The nurse should limit suctioning to less than 10 seconds per pass to minimize these risks and prevent complications such as mucosal damage and bleeding.
B) Set the suction pressure to 110 mm Hg: The appropriate suction pressure for endotracheal suctioning depends on various factors, including the client's age, condition, and clinical status. While suction pressures of 80 to 120 mm Hg are commonly used for adults, the specific pressure setting should be individualized based on the client's needs and should not exceed the safe range to prevent mucosal injury or hypoxemia.
D) Apply suction when inserting the catheter: Suction should be applied only during withdrawal of the catheter to minimize the risk of mucosal trauma and hypoxemia. Applying suction during catheter insertion can increase the risk of airway trauma and should be avoided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Asking the client to cough while inserting the NG tube:
This action is not necessary and may not be appropriate during the insertion of an NG tube. Coughing can increase the risk of gagging and aspiration during the procedure.
B) Wearing sterile gloves to insert the NG tube:
While the nurse should maintain appropriate hand hygiene, wearing sterile gloves is not typically necessary for the insertion of an NG tube. Clean gloves are sufficient for this procedure.
C) Placing the client into a left lateral position before inserting the NG tube:
Positioning the client in a high Fowler's position (sitting upright) or semi-Fowler's position is generally preferred for NG tube insertion to facilitate tube passage into the esophagus and reduce the risk of aspiration. Placing the client in a left lateral position is not typically done for NG tube insertion.
D) Determining the length of the NG tube to be inserted prior to the procedure:
This is the correct action. Before inserting the NG tube, the nurse should measure the distance from the tip of the client's nose to the earlobe and then from the earlobe to the xiphoid process or the mark on the NG tube corresponding to the desired insertion length. This helps ensure that the tube is inserted to the appropriate depth and reaches the desired location within the gastrointestinal tract.
Correct Answer is D
Explanation
A) Administer and teach about medications to suppress stage III sleep:
Suppressing stage III sleep is not a primary intervention for sleepwalking and could potentially disrupt the client’s overall sleep quality.
B) Encourage the child to verbalize feelings regarding sleep pattern:
While understanding feelings about sleep patterns may be helpful, it is not the immediate priority in managing sleepwalking.
C) Provide a quiet environment for nighttime sleep:
A quiet environment is generally beneficial for good sleep hygiene but does not directly address the safety concerns associated with sleepwalking.
D) Maintain patient safety during episodes of somnambulism:
Ensuring the client’s safety is the primary focus. Sleepwalking can lead to accidents or injuries; therefore, implementing safety measures to prevent harm during episodes of somnambulism is crucial. This may include securing the environment, using safety gates, and ensuring the client’s immediate surroundings are safe.
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