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. Cancer pain: Cancer pain can result from tumor growth, tissue invasion, or nerve compression caused by cancer. It can be acute or chronic and may vary in intensity. However, in this scenario, the client's pain is specifically associated with dermatitis resulting from radiation therapy, rather than directly from the cancer itself.

B. Acute pain: Acute pain is typically sudden in onset and is often associated with tissue injury or damage. In this case, the painful dermatitis resulting from radiation therapy would be considered acute pain because it is directly related to the recent tissue damage caused by the radiation. Acute pain is usually short-term and resolves as the underlying cause heals or is treated.

C. Chronic pain: Chronic pain persists beyond the expected time for tissue healing and is often associated with conditions such as arthritis or neuropathy. While cancer pain can sometimes become chronic if it persists over time, the pain described in this scenario is more likely to be acute given its association with recent radiation therapy.

D. Neuropathic pain: Neuropathic pain results from damage or dysfunction of the nervous system and can present as shooting or burning sensations. While neuropathic pain can occur in cancer patients, the pain described in this scenario is more likely to be acute and related to tissue damage from radiation therapy rather than neuropathy.

A. Irritable B. Lethargic C. Angry D. Decreased attention to detail

Correct Answer is D

Explanation

A) Irritable: Irritability is more closely associated with emotional responses to stress rather than cognitive responses. While irritability can be a manifestation of stress, it primarily reflects emotional tension rather than cognitive impairment.

B) Lethargic: Lethargy is a physical response to stress rather than a cognitive one. It refers to a lack of energy, motivation, or enthusiasm, which can result from stress-induced fatigue or exhaustion.

C) Angry: Anger is also primarily an emotional response to stress rather than a cognitive one. While stress can contribute to feelings of anger or frustration, it does not directly reflect cognitive impairment or alterations in cognitive functioning.

D) Decreased attention to detail: Cognitive responses to stress can include difficulty concentrating, decreased attention to detail, memory problems, and impaired decision-making. When a client demonstrates decreased attention to detail, it indicates cognitive impairment or distraction, which can be a response to stress. This behavior suggests that the client's cognitive functioning is affected by the stress they are experiencing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had radiation therapy and is experiencing painful dermatitis. The nurse should identify the client is experiencing which of the following types of pain?

Correct Answer is A

Explanation

After an assessment, the nurse realizes that a client demonstrates cognitive responses to stress. What behaviors did the client demonstrate for the nurse to make this clinical determination?

Correct Answer is D

Explanation

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