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 B,A,C,D,E
B. The nurse first prepares the equipment and ensures the suction pressure is set appropriately.
A. Sterile gloves are then applied to maintain sterile technique during airway 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. Taking a hot shower in the morning can help decrease stiffness and improve joint mobility for clients with rheumatoid arthritis. Heat therapy is beneficial for morning stiffness.
B. Cold packs should not be applied directly to the skin as it may cause skin damage. Cold therapy is used for inflammation, but not for prolonged periods on the skin.
C. Biological response modifiers are not used specifically to prevent infection; they modify immune response and may increase infection risk.
D. Clustering physical activities can lead to fatigue. The nurse should recommend spreading activities throughout the day to conserve energy.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
After notifying the provider, the nurse should first administer oxygen at 2 L/min via nasal cannula and then administer sublingual nitroglycerin
Rationale
Administer oxygen at 2 L/min via nasal cannula
The client is experiencing shortness of breath and chest pain with a decrease in oxygen saturation (92%), which is a concern, indicating that the client may be experiencing an acute cardiovascular event such as a myocardial infarction (MI). Administering oxygen helps to increase the oxygen supply to the heart and other vital organs.
Administer sublingual nitroglycerin
Nitroglycerin is a vasodilator that can help relieve chest pain associated with conditions like angina or myocardial infarction by increasing blood flow to the heart and reducing myocardial oxygen demand. The client’s pain level has increased to 7/10 on the pain scale, which suggests the chest pain may be related to an acute cardiac event.
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