A nurse is caring for an adult client who requires nasopharyngeal suctioning. Which of the following actions should the nurse take?
Set the suction device to 120 mm Hg.
Apply suction to the catheter during insertion.
Have the client tuck his chin to his chest during suctioning.
Apply a petroleum-based lubricant to the catheter.
The Correct Answer is A
A. Set the suction device to 120 mm Hg: For nasopharyngeal suctioning in adults, the suction pressure should typically be set between 100 and 120 mm Hg to prevent injury to the mucous membranes while effectively clearing secretions.
B. Apply suction to the catheter during insertion: Suction should not be applied during insertion of the catheter, as this can cause trauma to the mucous membranes. Suctioning should only occur when the catheter is in the appropriate position and being withdrawn.
C. Have the client tuck his chin to his chest during suctioning: The client should not tuck the chin to the chest during suctioning. Instead, the client should be asked to either cough or breathe normally. Tucking the chin may obstruct the airway and make suctioning difficult.
D. Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used as they can cause a fire hazard when oxygen is present. Instead, a water-soluble lubricant should be applied to the catheter if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assess the client every hr for circulation, possible injury, and readiness for discontinuation: While regular assessment is necessary, it should be done more frequently than every hour. A check every 15-30 minutes is recommended for safety.
B. Check the client's peripheral pulses and skin integrity every 15 min: Frequent assessments of circulation, skin integrity, and injury help prevent complications like tissue damage or nerve impairment.
C. Assist the client with passive range of motion exercises every 3 hr: Passive range of motion exercises should be done more frequently than every 3 hours to prevent stiffness and joint contractures.
D. Attach the extremity restraint straps to the bed rails using a quick-release buckle: Restraints should never be attached to bed rails, as this increases injury risk. Straps should be secured to a stationary part of the bed frame.
Correct Answer is A
Explanation
A. Patient’s name: The client’s name is the most reliable and direct way to identify a client. It should be verified using two identifiers (e.g., name and date of birth) to ensure the correct client is receiving care.
B. Room number: While room numbers are helpful in identifying a location, they should not be used as the primary method for client identification. Two clients could be in the same room, so room number alone is not sufficient.
C. Telephone number: A client’s telephone number is not an appropriate identifier for performing a focused assessment, as it is not unique to the patient’s identity in a healthcare setting.
D. Diagnosis: The diagnosis is important for the care plan but should not be used to identify the client. Multiple clients may have the same diagnosis, so it cannot serve as a unique identifier.
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