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
A. Atrial fibrillation: This dysrhythmia is characterized by an irregularly irregular rhythm with absent or unidentifiable P waves, not a prolonged constant P-R interval.
B. Premature atrial complexes: PACs involve early P waves that may have a normal or slightly different P-R interval, but they do not cause a consistently prolonged P-R interval across all beats.
C. First-degree atrioventricular block: A constant P-R interval greater than 0.20 seconds indicates a first-degree AV block. The atrial impulses are delayed at the AV node, but all impulses are conducted to the ventricles, producing a regular rhythm with prolonged P-R intervals.
D. Complete heart block: In complete heart block (third-degree AV block), there is no relationship between P waves and QRS complexes. The P-R interval is variable, unlike the constant prolongation seen in first-degree AV block.
Correct Answer is A
Explanation
Rationale:
A. Check the cords of the IV pump for fraying: Inspecting electrical cords for fraying or damage is an important safety step before use. Damaged cords can cause electrical shock, fire hazards, or equipment malfunction, so this helps ensure safe operation.
B. Remove the safety inspection sticker before plugging in the IV pump: Safety inspection stickers indicate that the device has passed electrical and functional safety checks. Removing them would eliminate visible proof of inspection and is not necessary for safe use.
C. Ensure that the electric outlet has two prongs for the IV pump: Medical equipment such as IV pumps should be plugged into grounded three-prong outlets to reduce the risk of electrical shock. Two-prong outlets do not provide this grounding protection.
D. Grasp the IV pump cord when unplugging it from the electrical outlet: Pulling on the cord can damage the internal wires and increase the risk of electrical hazards. The correct method is to grasp the plug itself when disconnecting from the outlet.
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