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 Suctioning should only occur when the catheter is in the appropriate position and being withdrawn.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 A
Explanation
A. The client reports frequently having a headache in the morning: Frequent morning headaches can indicate sleep-related issues such as sleep apnea or bruxism (teeth grinding), both of which can significantly affect sleep quality and overall health.
B. The client reports having vivid dreams about their childhood: Vivid dreams can occur naturally, especially during rapid eye movement (REM) sleep. Although they may be unusual, they are not typically a cause for concern.
C. The client reports taking 30 min to fall asleep on average: Taking up to 30 minutes to fall asleep is within normal limits for most people. This is not a concerning finding and does not necessarily require reporting unless the client is experiencing other sleep disturbances.
D. The client reports sleeping about 7 hr on average: Sleeping around 7 hours per night is considered within the normal range for most adults. This is generally adequate sleep, and there is no indication of a significant issue that would require reporting to the provider.
Correct Answer is A
Explanation
A. This image shows well-demarcated, erythematous plaques covered with silvery-white scales—classic features of plaque psoriasis. These lesions typically appear on extensor surfaces like the elbows, knees, and scalp, and may itch or crack.
B. This image shows a yellow crusting lesion which suggests impetigo or a secondary skin infection, not psoriasis. Impetigo typically presents with honey-colored crusts, caused by bacterial infection, usually. Psoriasis lesions are usually dry and scaly, not moist or oozing.
C. This image shows red bumps on arm suggesting an allergic reaction, folliculitis, or possibly contact dermatitis. These are small papules often scattered or in clusters, and do not have the thick scaling seen in psoriasis.
D. The fourth image shows linear striae-like marks likely striae distensae (stretch marks), unrelated to psoriasis. Stretch marks are atrophic, linear scars typically due to skin stretching from growth or weight changes. They lack inflammation, plaques, and scale—all key signs of psoriasis.
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