A nurse is nasopharyngeal suctioning an adult patient to remove thick secretions. The nurse will:

use a 14-Fr catheter

use suction pressure between 120 and 160 mm Hg

use an 8-Fr catheter

use the catheter to suction the mouth and nasopharynx

Answer and Explanation

The Correct Answer is A

A. Use a 14-Fr catheter: This is the appropriate size for suctioning an adult to effectively remove thick secretions.
B. Use suction pressure between 120 and 160 mm Hg: This pressure is too high and may cause mucosal damage; 100 to 120 mm Hg is recommended for adults.
C. Use an 8-Fr catheter: This size is too small for effectively suctioning thick secretions in adults.
D. Use the catheter to suction the mouth and nasopharynx: Suctioning the mouth first contaminates the catheter, increasing the risk of infection in the nasopharynx.

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Correct Answer is A

Explanation

A. Jaundiced: The yellow discoloration of the skin can interfere with light absorption, affecting the accuracy of the reading.
B. Febrile: An elevated body temperature does not affect the pulse oximeter's accuracy.
C. Obese: Subcutaneous fat does not interfere with the device's light absorption or reading accuracy.
D. Dark-skinned: Higher melanin levels can affect the absorption of light, leading to less accurate readings.

A. Perform tracheostomy care for the client every 4 hr. B. Place the client in a lateral recumbent position prior to tracheostomy care. C. Clean the tracheostomy stoma with a chlorhexidine solution. D. Preoxygenate the client for 10 seconds prior to tracheostomy care.

Correct Answer is D

Explanation

A. Perform tracheostomy care for the client every 4 hr: Tracheostomy care is performed based on the assessment of the need for cleaning and secretion management rather than a fixed time schedule.
B. Place the client in a lateral recumbent position prior to tracheostomy care: This position does not facilitate optimal visualization of the tracheostomy site. The Fowler's or semi-Fowler's position is preferred.
C. Clean the tracheostomy stoma with a chlorhexidine solution: Chlorhexidine is too harsh for mucosal surfaces and can cause irritation. Normal saline is recommended for cleaning.
D. Preoxygenate the client for 10 seconds prior to tracheostomy care: Preoxygenation for at least 30 to 60 seconds is recommended to prevent hypoxia during suctioning.

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A nurse is nasopharyngeal suctioning an adult patient to remove thick secretions. The nurse will:

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Naxlex Comprehensive Predictor Exams

The nurse takes into consideration that a pulse oximeter may not give an accurate reading if the patient is:

Correct Answer is A

Explanation

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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