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 C

Explanation

A. Check residual volume every 4 to 6 hr: While checking residual volume is an essential component of enteral feeding management, it is not the priority action in this scenario. The client's positioning to prevent aspiration takes precedence over checking residual volume.

B. Observe client's respiratory status: Monitoring respiratory status is crucial for any client with a decreased level of consciousness. However, in this case, the priority is to prevent aspiration, and positioning takes precedence over respiratory assessment.

C. Elevate the head of the client's bed 30° to 45°: The priority action for a client receiving continuous enteral feedings via a gastrostomy tube and experiencing a decreased level of consciousness is to maintain proper positioning to prevent aspiration. Elevating the head of the bed 30° to 45° helps reduce the risk of aspiration by promoting drainage of stomach contents away from the airway. This position also helps prevent reflux of gastric contents into the esophagus, which can lead to aspiration pneumonia.

D. Monitor intake and output every 8 hr: Monitoring intake and output is essential for assessing fluid balance and the effectiveness of enteral feedings. However, it is not the priority action in this situation compared to maintaining proper positioning to prevent aspiration.

A. Yoga B. Electromagnetic therapy C. Meditation D. Acupuncture E. Biofeedback

Correct Answer is ["A","C","D","E"]

Explanation

Answer: A, C, D, E

Rationale:

A) Yoga: Yoga is an effective nonpharmacological therapy that combines physical postures, breathing exercises, and meditation, which can help reduce stress, improve flexibility, and enhance mental focus.

B) Electromagnetic therapy: Electromagnetic therapy is typically used for pain management or to promote wound healing rather than stress reduction. It is not commonly included in stress management techniques.

C) Meditation: Meditation focuses on mindful breathing and awareness, which can significantly reduce stress by calming the mind and improving emotional resilience. It’s widely used to help manage stress and anxiety.

D) Acupuncture: Acupuncture involves the insertion of needles at specific body points and is believed to release endorphins and balance energy flow, which can reduce stress and promote relaxation.

E) Biofeedback: Biofeedback teaches clients to control physiological responses like heart rate and muscle tension, helping them manage stress and anxiety effectively through self-regulation techniques.

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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 planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

A nurse is teaching a class about nonpharmacological therapies to decrease stress. The nurse should include which of the following therapies? (Select All that Apply)

Correct Answer is ["A","C","D","E"]

Explanation

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