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 A
Explanation
A) Anxiety: Anxiety is a subjective finding because it represents the client's perception of their emotional state. It is a feeling of unease, worry, or fear, which the client reports experiencing. Subjective findings are based on the client's self-report or feelings.
B) Alert: Being alert is an objective finding because it refers to the client's level of consciousness and responsiveness to stimuli. In this scenario, the nurse assesses that the client is alert based on their ability to respond appropriately to questions and stimuli in the environment.
C) Pacing: Pacing is an objective finding because it describes observable behavior. In this case, the nurse observes the client pacing in the room, which is a physical activity that can be seen or measured.
D) Restless: Restlessness is an objective finding because it describes observable behavior. The nurse assesses that the client appears restless based on their observed behavior of pacing in the room. Restlessness is a physical manifestation of the client's anxiety and is observable by others.
Correct Answer is D
Explanation
A) Pain level:
While assessing pain is important to determine the effectiveness of the pain management, it is not the immediate priority after administering an opioid.
B) Pulse oximetry:
Monitoring oxygen saturation is critical as opioids can depress respiratory function. However, it is indirectly related to the primary effect of the medication on the central nervous system.
C) Blood pressure:
Monitoring blood pressure is important as opioids can cause hypotension, but it is not as critical as monitoring the level of sedation and respiratory status.
D) Level of sedation:
This is the priority because opioids can cause significant sedation and respiratory depression. Assessing the level of sedation helps determine if the client is at risk of further complications like respiratory arrest. Over-sedation can be a precursor to more serious complications, making this assessment crucial.
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