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 Suctioning should only occur when the catheter is in the appropriate position and being withdrawn.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 D
Explanation
A. Read the medication label twice prior to administration: Best practice requires reading the label three times (when retrieving, preparing, and before administering), so reading it only twice is insufficient for safety.
B. Ask the client if they have ever taken a similar medication: While helpful, this does not replace the need for the nurse to verify the medication's action, side effects, and interactions independently.
C. Use one patient identifier prior to medication administration: Safe practice requires using two patient identifiers (e.g., name and date of birth), so using only one is inadequate and unsafe.
D. Access the online drug formulary for an unfamiliar medication: This ensures the nurse understands the medication's purpose, dosage, side effects, and contraindications, which is critical for safe first-time administration.
Correct Answer is A
Explanation
A. "Let me clarify that you want the medication given gid, correct?": When receiving a telephone prescription, it is essential to clarify any unclear aspects of the order, such as the dosage frequency. This ensures that the prescription is accurately understood and implemented and helps prevent medication errors.
B. "Will you please spell the name of that medication for me?": Although confirming the medication name is important, it is more critical to clarify the specific directions for administering the medication, such as the frequency, rather than spelling.
C. "I will sign my name now and leave a space for you to sign your name.": Offering to leave a space for the provider's signature is standard practice. However, it's not the most critical communication safety check during the verbal order itself.
D. "Let me provide you with the client's medical record number for identification.": While important for ensuring correct patient identification, the nurse should first focus on accurately obtaining the medication prescription and other critical details before providing identification information.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.