A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Don sterile gloves.
Turn on the suction and set the pressure.
Insert the catheter during the client's inspiration.
Apply suction while rotating the catheter.
Rinse the catheter to remove secretions.
The Correct Answer is A,B,C,D,E
A. The nurse should begin by donning sterile gloves to maintain a sterile field.
B. The suction machine should be turned on, and the pressure should be set before starting the suctioning.
C. The catheter should be inserted during the client’s inspiration to minimize discomfort and maximize
effectiveness.
D. Suction should be applied while rotating the catheter to prevent tissue damage and to clear secretions effectively.
E. After suctioning, the catheter should be rinsed to remove any remaining secretions.
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Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
The nurse should first anticipate the need to Obtain IV access then Prepare to administer IV fluids.
Rationale
First Anticipated Step: Obtain IV Access:
In a client with hypotension and anemia, immediate IV access is crucial to administer fluids or blood
products to stabilize the client’s condition before the endoscopy. Given the client’s low blood pressure and heart rate, they may need IV fluids (such as saline or Ringer's lactate) to help improve circulation and maintain perfusion. This is essential before proceeding with further interventions like the planned endoscopy.
Second Anticipated Step:
Prepare to administer IV fluids:
The client's low blood pressure and the potential for significant blood loss suggest that IV fluids will be necessary to restore blood volume and improve hemodynamic stability before endoscopy. Normal saline or Lactated Ringer's are commonly used for volume resuscitation in this scenario.
Correct Answer is D
Explanation
A. Encouraging the client to spend time in the dayroom may increase stimulation and worsen manic symptoms. A quiet, calm environment is typically more beneficial.
B. Withdrawing privileges is punitive and may escalate agitation or irritability in a client with mania.
C. Seclusion should only be used if the client is a danger to themselves or others. It is not a first-line intervention for anxiety or manic symptoms.
D. Encouraging the client to take frequent rest periods helps manage manic symptoms by preventing fatigue and promoting some level of structure and control over their activities.
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