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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Preparing the client for an MRI is not the first step; assessment of neurological status is the priority.
B. Inserting an indwelling urinary catheter is unnecessary unless indicated after further assessment.
C. Determining the Glasgow Coma Scale score is the most important initial step to assess the client's neurological status and guide further interventions.
D. Administering mannitol is appropriate for increased intracranial pressure but should only be done after assessing the client's neurological condition.

A. A noncoring needle B. An angiocatheter C. A butterfly needle D. A 25-gauge needle

Correct Answer is A

Explanation

A. A noncoring needle is specifically designed to access venous access ports without damaging the port, making it the appropriate choice.
B. An angiocatheter is used for peripheral IV insertion, not for accessing an implanted port.
C. A butterfly needle is used for short-term venous access, not for implanted ports.
D. A 25-gauge needle is too small for accessing an implanted port and would not be effective.

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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.)

Nursing Test Bank

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