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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Rationale:
- Polyhydramnios: Excess amniotic fluid can overdistend the uterus, reducing its ability to contract effectively after delivery, which increases the risk of uterine atony and postpartum hemorrhage.
- Prolonged rupture of membranes: A long duration of ruptured membranes increases the risk of bacteria ascending into the uterus, which can lead to endometritis and systemic infection postpartum.
- Prenatal anemia: Low hemoglobin levels reduce oxygen delivery to tissues and impair the immune response, increasing susceptibility to infections such as endometritis or wound infection after cesarean birth.
- High parity: Multiple pregnancies can cause stretching and weakening of the uterine muscle, which may result in inadequate contraction postpartum, predisposing the client to uterine atony.
Correct Answer is A
Explanation
A. Tell the client, "You seem to be very upset.": Using verbal de-escalation and acknowledging the client’s emotions can help reduce agitation. This approach demonstrates empathy, promotes communication, and can prevent escalation.
B. Use a face shield with a mask when providing care to the client: Personal protective equipment is important for infection control, but it does not address the behavioral escalation or help calm an agitated client.
C. Initiate seclusion protocol: Seclusion is a restrictive intervention used only if the client poses an imminent risk of harm. It is not the first step in managing agitation and should follow attempts at de-escalation.
D. Engage the panic alarm: Activating the panic alarm is appropriate in situations of immediate danger, but for verbal agitation and pacing without aggression, de-escalation is the first intervention.
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