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 D

Explanation

Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) by the lungs, leading to an accumulation of CO2 and a decrease in pH.

Analysis:

pH 7.22: Indicates acidemia (pH below 7.35), suggesting acidosis.

PaCO2 68 mm Hg: Elevated PaCO2 indicates hypoventilation, which is characteristic of respiratory acidosis.

Base excess -2: Base excess is within normal limits and does not contribute significantly to the acid-base imbalance in this scenario.

PaO2 78 mm Hg: PaO2 is slightly low but not significantly contributing to the acid-base imbalance.

Saturation 80%: Oxygen saturation is low, indicating hypoxemia, which is commonly associated with respiratory acidosis due to hypoventilation.

Bicarbonate 26 mEq/L: Bicarbonate is within normal limits, suggesting compensation for the respiratory acidosis, which is a chronic condition.

Overall, the ABG values indicate respiratory acidosis due to inadequate ventilation, leading to CO2 retention and subsequent acidemia.

A. Raise the bed to a comfortable height. B. Stand on the left side of the bed C. Raise the side rat on the working side of the bed. D. Use the non-dominant hand to insert the catheter.

Correct Answer is A

Explanation

A. Raise the bed to a comfortable height:
Raising the bed to a comfortable height is essential for proper body mechanics and preventing back strain. It ensures the nurse can perform the procedure efficiently and safely.

B. Stand on the left side of the bed:
While a left-handed nurse might prefer to stand on the left side for better access, this choice depends on the room layout and client position. Standing on the side where the nurse is most comfortable is essential, but it is not the primary action compared to ensuring proper bed height.

C. Raise the side rail on the working side of the bed:
Raising the side rail on the working side of the bed could obstruct the nurse's access to the client and is not generally recommended during procedures requiring close access to the client.

D. Use the non-dominant hand to insert the catheter:
The dominant hand, in this case, the left hand, should be used to insert the catheter for better control and precision. The non-dominant hand is typically used to hold the genitalia and provide stability.

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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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Naxlex Comprehensive Predictor Exams

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? PH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L

Correct Answer is D

Explanation

A nurse who is left-handed is preparing to perform a straight catheterization for a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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