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 D
Explanation
D. 28%:
When a client receives oxygen via a nasal cannula at a flow rate of 2 L/min, the approximate inspired oxygen concentration is around 24-28%. This is because each liter of oxygen delivered through a nasal cannula adds approximately 4% to the baseline room air concentration of 21%. Therefore, at 2 L/min, the client would be receiving approximately 24-28% inspired oxygen concentration.
A. 36%, B. 70%, C. 50%:
These percentages are not consistent with the oxygen concentration delivered via a nasal cannula at 2 L/min. Higher flow rates or alternative oxygen delivery systems, such as masks or high-flow nasal cannula, would be needed to achieve these concentrations.
Correct Answer is A
Explanation
A) Severity: When the nurse asks the client to rate the pain on a scale of 0 to 10, they are assessing the severity of the pain. This component of the PQRST mnemonic focuses on understanding the intensity or severity of the pain experienced by the client. By asking the client to quantify their pain on a scale, the nurse gains insight into how much the pain is affecting the client's well-being and can use this information to guide pain management interventions.
B) Precipitating cause: This component of the PQRST mnemonic involves identifying factors that trigger or worsen the pain. Asking about activities or events that preceded the onset of pain helps the nurse understand the precipitating cause.
C) Region: This component involves identifying the specific location or region of the body where the pain is experienced. It helps the nurse localize the pain and identify potential underlying causes.
D) Quality: This component involves asking the client to describe the characteristics or quality of the pain, such as sharp, dull, stabbing, or burning. Understanding the quality of the pain provides additional information about its nature and possible underlying mechanis
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