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 C
Explanation
Rationale:
A. "Refrain from doing any exercises until your symptoms show improvement.": Completely avoiding exercise is not necessary for most people with asthma and can negatively impact cardiovascular health. The goal is to control symptoms so that safe activity is possible.
B. "Use your long-acting beta agonist inhaler after exercise-induced symptoms appear.": Long-acting beta agonists are used for maintenance therapy, not for quick relief. They are not appropriate for immediate symptom control before or after exercise.
C. "Use your short-acting beta agonist inhaler before exercising.": Short-acting beta agonists, such as albuterol, can be taken 5–20 minutes before exercise to prevent exercise-induced bronchospasm. This is the recommended approach for clients with exercise-triggered asthma.
D. "It is safe to exercise if your peak flow meter measures in the red zone.": The red zone indicates severe airway narrowing and poor asthma control, requiring immediate medical attention. Exercise in this state could worsen symptoms and lead to respiratory distress.
Correct Answer is C
Explanation
Rationale:
A. Tetracycline 200 mg PO: This prescription is incomplete because it does not specify the frequency or duration of administration, making it unclear how the medication should be given safely.
B. Cimetidine PO twice daily: The prescription lacks the dosage strength in milligrams, which is essential for accurate administration and safe dosing.
C. Digoxin 0.25 mg PO daily: This prescription includes the medication name, dosage, route, and frequency, providing all essential components needed for safe administration.
D. Epoetin alfa 150 units/kg three times weekly: While it includes dose and frequency, it does not specify the route (subcutaneous or IV), which is required to complete the prescription safely.
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