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 D
Explanation
Rationale:
A. A colleague who uses assertive communication: Assertive communication is a positive professional skill that promotes clarity and mutual respect. It involves expressing needs and opinions confidently while respecting the rights of others, not bullying behavior.
B. A colleague who is mindful of the personal space of other colleagues: Respecting personal space reflects professional courtesy and helps maintain a comfortable work environment. It does not represent any form of bullying or intimidation.
C. A colleague who negotiates with others for a win-win situation: Negotiation aimed at mutual benefit demonstrates collaboration and problem-solving, which are constructive workplace behaviors, not bullying tactics.
D. A colleague who finds fault with other colleagues: Habitually criticizing or fault-finding without constructive intent is a form of workplace bullying. This behavior undermines morale, creates a hostile environment, and can damage professional relationships.
Correct Answer is B
Explanation
A. Playing with a jump rope: Jump rope requires advanced gross motor coordination and balance, which typically develops around age 4–5 years. A 30-month-old is not developmentally ready for this activity.
B. Playing with a large plastic truck: Toddlers around 2–3 years enjoy manipulating large toys such as trucks, cars, or blocks. This play supports fine and gross motor skills, hand-eye coordination, and imaginative exploration appropriate for their developmental stage.
C. Playing with dress-up clothes: Pretend or dress-up play becomes more common around age 3–4 years, as symbolic thinking and role-playing abilities develop. A 30-month-old may begin simple pretend play but usually engages in more concrete, manipulative play.
D. Playing with an imaginary friend: Engaging in complex imaginative play, such as interacting with an imaginary friend, usually emerges around age 3–4 years, reflecting more advanced cognitive and social development than expected at 30 months.
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