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 B
Explanation
A) Transport the patient safely and quickly when going to the radiology department: While it's important to transport patients safely and efficiently, this action does not directly address the prevention of disease spread associated with contact precautions. Contact precautions primarily involve preventing direct or indirect contact with the patient's bodily fluids or contaminated surfaces.
B) Use a dedicated blood pressure cuff that stays in the room and is used for that patient only: This is the most appropriate action for preventing the spread of disease on contact precautions. Using dedicated equipment for the patient reduces the risk of cross-contamination between patients. It helps prevent the transmission of pathogens from one patient to another through contaminated equipment.
C) Place the patient in a room with negative airflow: Negative airflow rooms are typically used for patients on airborne precautions to prevent the spread of airborne pathogens. While maintaining appropriate airflow is important for infection control, it is not specific to contact precautions.
D) Wear a gown, gloves, face mask, and goggles for interactions with the patient: This option describes the appropriate personal protective equipment (PPE) to wear when caring for a patient on contact precautions. While it's important to wear PPE, using dedicated equipment for the patient is more directly related to preventing disease spread in this scenario
Correct Answer is B
Explanation
A. Hyponatremia: Hyponatremia is characterized by low sodium levels in the blood and can lead to symptoms such as weakness, confusion, and seizures. While hyponatremia can contribute to fluid imbalance, the client's presentation with shortness of breath, lower extremity swelling, crackles in the lungs, and elevated blood pressure is more indicative of fluid volume excess rather than hyponatremia.
B. Hypervolemia: Hypervolemia, or fluid volume excess, occurs when there is an abnormal increase in the extracellular fluid volume. This can lead to symptoms such as shortness of breath, crackles in the lungs (indicative of pulmonary edema), peripheral edema, and elevated blood pressure. Given the client's reported symptoms and assessment findings, hypervolemia is the most likely diagnosis.
C. Hypovolemia: Hypovolemia, or fluid volume deficit, occurs when there is a decrease in the extracellular fluid volume. This condition is characterized by symptoms such as thirst, dry mucous membranes, decreased urine output, and hypotension. The client in this scenario presents with signs and symptoms consistent with fluid volume excess rather than hypovolemia.
D. Hyperkalemia: Hyperkalemia is characterized by elevated potassium levels in the blood and can lead to symptoms such as muscle weakness, cardiac dysrhythmias, and nausea. While hyperkalemia can occur in clients with end-stage kidney disease, the client's reported symptoms and assessment findings are more suggestive of fluid volume excess rather than hyperkalemia.
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