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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Soreness and redness may occur with new ostomies, but persistent irritation may indicate a problem.
B. Red, irritated, and moist skin around the stoma site suggests a leak in the appliance, and the skin barrier needs replacing.
C. The assessment does not suggest a malfunction in ostomy function but rather a skin integrity issue.
D. Overhydration is not typically associated with skin irritation around the stoma.

A. Produces bronchodilation B. Increases oxygen saturation C. Decreases systole D. Decreases compliance

Correct Answer is D

Explanation

A. Emphysema is not associated with bronchodilation; it is characterized by the destruction of alveoli.
B. Emphysema does not directly increase oxygen saturation; it impairs gas exchange.
C. Emphysema does not affect systole; it primarily affects lung function.
D. Emphysema decreases lung tissue elasticity, leading to decreased compliance, making it harder for the lungs to inflate and deflate.

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A nurse has received an order to suction a patient's endotracheal tube. Which action is most appropriate when performing this intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is complaining of soreness around the stoma site. The nurse notes proper drainage in the bag, however, the surrounding skin is red, irritated, and moist. How will the nurse interpret this assessment?

Correct Answer is B

Explanation

The nurse understands that emphysema decreases lung tissue elasticity. How does this affect lung inflation?

Correct Answer is D

Explanation

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