A nurse is caring for a client who has a new tracheostomy. Which of the following actions should the nurse take when suctioning the client's tracheostomy?

Set the suction source at 220 mm Hg.

Repeat suctioning as needed up to five times.

Hyperventilate the client with 100% oxygen before suctioning.

Suction for 20 seconds with each pass.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Set the suction source at 220 mm Hg: This pressure is excessively high and can damage tracheal mucosa. Recommended suction pressure for an adult tracheostomy is typically 80–120 mm Hg to minimize tissue trauma while effectively clearing secretions.

B. Repeat suctioning as needed up to five times: Frequent suction passes increase the risk of hypoxia and mucosal injury. Generally, suctioning should be limited to a maximum of three passes per session, allowing adequate recovery and reoxygenation between attempts.

C. Hyperventilate the client with 100% oxygen before suctioning: Preoxygenating helps prevent hypoxemia during suctioning by increasing oxygen reserves. This is a standard safety measure, especially in clients with artificial airways, to maintain oxygenation during the procedure.

D. Suction for 20 seconds with each pass: Prolonged suctioning increases the risk of hypoxia, arrhythmias, and airway trauma. Each suction pass should be limited to 10–15 seconds for adults to reduce complications and promote safety.

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Correct Answer is D

Explanation

A. Weight gain 2.3 kg (5 lb): Mild weight gain can occur with oral contraceptive use and is generally not dangerous. This finding does not require immediate reporting.

B. Frequent nausea: Nausea is a common side effect, especially during the first few months of therapy. While bothersome, it is usually not an urgent concern unless severe or persistent.

C. Breast tenderness: Breast tenderness is a common, mild side effect of oral contraceptives and does not typically indicate a serious problem requiring immediate intervention.

D. Persistent headache: A new, persistent, or severe headache can indicate vascular complications, such as hypertension or increased risk of thromboembolism, which are serious adverse effects of oral contraceptives. This finding requires immediate reporting.

A. Implement activities that promote the client's self-esteem. B. Offer a list of smoking cessation support groups. C. Provide education about the dangers of smoking. D. Determine the client's coping methods.

Correct Answer is D

Explanation

Rationale:

A. Implement activities that promote the client's self-esteem: While boosting self-esteem can support smoking cessation, it is not the first priority. The nurse must first assess the client’s current coping strategies to tailor the cessation plan.

B. Offer a list of smoking cessation support groups: Providing resources is helpful, but without assessing the client’s needs and coping methods first, the support may not be appropriately matched to the client’s situation.

C. Provide education about the dangers of smoking: Education is important, but most clients are already aware of the health risks. Effective teaching requires first understanding the client's motivation and coping mechanisms.

D. Determine the client's coping methods: Assessment is always the initial step in the nursing process. Identifying how the client currently manages stress will help the nurse create an individualized and effective cessation plan.

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A nurse is caring for a client who has a new tracheostomy. Which of the following actions should the nurse take when suctioning the client's tracheostomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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