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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) "Would you like to talk about your concerns?": This response acknowledges the client's feelings and offers support and an opportunity to discuss their concerns further. It respects the client's autonomy and allows them to express their thoughts and feelings about the situation.
B) "Why don't you want to tell your partner your diagnosis?": This response may come across as confrontational and judgmental, potentially making the client feel defensive. It does not facilitate open communication or address the client's concerns in a supportive manner.
C) "If I were you, I would tell my partner.": This response imposes the nurse's values and beliefs on the client, which may not be helpful or appropriate. It undermines the client's autonomy and decision-making process.
D) "Most people find it helpful to talk to their partner.": While this statement may be true for some individuals, it assumes that the client's situation is the same as others and does not take into account the client's unique circumstances and preferences. It does not encourage open dialogue or address the client's concerns directly.

A. Disenfranchised grief B. Anticipatory grief C. Prolonged grief D. Uncomplicated grief

Correct Answer is D

Explanation

A) Disenfranchised grief:
Disenfranchised grief occurs when a person's loss is not socially recognized or supported, such as the death of a pet or an ex-spouse. The client's situation does not indicate disenfranchised grief.

B) Anticipatory grief:
Anticipatory grief happens before an impending loss, such as when a loved one is terminally ill. The client is grieving after the loss, not before it.

C) Prolonged grief:
Prolonged grief, also known as complicated grief, involves intense, persistent, and disabling grief symptoms that interfere with normal functioning. The client’s decreasing grief and positive outlook indicate that they are not experiencing prolonged grief.

D) Uncomplicated grief:
Uncomplicated grief, also known as normal grief, is the natural response to loss. It includes a range of emotions and reactions that typically diminish over time as the individual adapts to the loss. The client’s decreasing grief severity and forward-looking attitude towards spending time with their grandchildren are characteristic of uncomplicated grief.

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A home health nurse is teaching about endotracheal suctioning. Which of the following information should the nurse include in the teaching?

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