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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A recent hip arthroplasty puts the client at risk for bleeding if alteplase is administered, as there is a potential for hemorrhage at the surgical site.
B. Acute renal failure may affect medication clearance but is not a contraindication for alteplase.
C. Chronic obstructive pulmonary disease (COPD) does not place the client at risk for alteplase therapy.
D. A family history of malignant hypertension does not directly affect the safety of alteplase therapy.
Correct Answer is C
Explanation
A. Platelet count is important for assessing clotting, but INR is more relevant for monitoring warfarin therapy.
B. Fibrinogen levels are not the primary measure for warfarin management.
C. The INR (International Normalized Ratio) is the key test used to adjust warfarin dosing, as it measures the clotting tendency.
D. aPTT is useful for monitoring heparin therapy, not warfarin.
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