A nurse has received an order to suction a patient's endotracheal tube. Which action is most appropriate when performing this intervention?
Occlude the Y-port when inserting the catheter
Limit the application of suction to 20-30 seconds
Assist the client into a supine position in preparation for suctioning.
Use sterile saline to moisten the end of the suction catheter
The Correct Answer is B
A. Occluding the Y-port during insertion is not a standard practice and may impede proper suctioning.
B. Limiting the application of suction to 20-30 seconds helps prevent hypoxia and tissue damage.
C. Assisting the client into a supine position is not a standard practice for endotracheal tube suctioning.
D. Using sterile saline to moisten the end of the suction catheter may introduce unnecessary moisture into the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["660"]
Explanation
To calculate the total output for this patient, we need to add up the amount of fluid that he lost through urination and emesis. Urination is the process of expelling urine from the body, and emesis is the medical term for vomiting. The patient urinated 300mL in the morning and 300mL at lunch, so the total amount of urine output is 600mL. The patient also had 60mL of emesis after lunch, so the total amount of emesis output is 60mL. Therefore, the total output for this patient is 600mL + 60mL = 660mL.
Correct Answer is B
Explanation
A. Love and belonging needs are related to social interactions and relationships, not directly addressed by hand hygiene and sterile techniques.
B. Safety and security needs are met by practices such as careful hand hygiene and sterile techniques that prevent infection and ensure a safe environment.
C. Self-esteem needs involve self-respect and confidence, not directly addressed by the nurse's infection control measures.
D. Physiologic needs encompass basic requirements for survival, including hygiene and infection prevention, but safety and security needs are a more specific fit.
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