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,B,E,C,A
Explanation
Rationale:
A. Record information about the home visit according to agency policy: Documentation is performed at the end of the visit to ensure that all observations, interventions, and plans are accurately recorded in the client’s record for continuity of care.
B. Contact the family to determine availability and readiness to make an appointment: Before visiting, the nurse should coordinate with the family to schedule a convenient time, ensuring that they are prepared for the assessment and intervention process.
C. Discuss plans for future visits with the family: After assessing the client and identifying needs, the nurse should collaborate with the family to plan ongoing visits and care strategies that align with their goals and availability.
D. Clarify the reason for the referral with the provider's office: This is the first step to ensure the nurse understands the purpose of the referral, specific concerns, and any important background information before contacting the family.
E. Identify family needs and interventions using the nursing process: During the visit, the nurse collects data, assesses needs, and develops appropriate interventions, forming the foundation for the care plan moving forward.
Correct Answer is B
Explanation
Rationale:
A. Perform an ECG every 12 hr: Frequent ECGs are typically done during the acute phase to monitor for arrhythmias, but by day 3 post-MI, continuous or as-needed monitoring is more appropriate unless new symptoms occur.
B. Obtain a cardiac rehabilitation consultation: Early involvement of cardiac rehab supports gradual activity progression, lifestyle modification, and psychosocial support, improving long-term outcomes after MI.
C. Draw a troponin level every 4 hr: Troponin testing is most useful for diagnosing and trending damage during the first 24 hours; by day 3, levels have usually peaked and are declining.
D. Place the client in a supine position while resting: Supine positioning can increase cardiac workload; a semi-Fowler's position is preferred to reduce venous return and ease breathing.
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