A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?
Insert the catheter 10 cm (4 in..
Apply suction while inserting the catheter.
Apply intermittent suction for 30 seconds.
Wait 1 min between suctioning attempts.
The Correct Answer is D
A. In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.
B. Suction should not be applied while inserting the catheter, as it could cause trauma to the mucosa and increase discomfort. Suction should only be applied while withdrawing the catheter, and it should be done intermittently to avoid injury and reduce the risk of hypoxia.
C. Suctioning should not exceed 10-15 seconds at a time to prevent hypoxia and other complications. Prolonged suctioning can lead to oxygen depletion and potential respiratory distress in the client.
D. Waiting at least 1 minute between suctioning attempts allows the client to recover and helps maintain adequate oxygenation. This pause is essential to prevent hypoxia and to ensure the client has time to breathe normally before the next suctioning attempt.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. This situation involves a potential medication error due to the electronic IV pump delivering excessive fluid, which requires documentation and an incident report for reporting and tracking purposes.
B. While observing another nurse's practice is important, the scenario does not involve an incident that requires reporting via an incident report.
C. This situation may warrant a medication incident report, but the family member's administration of PCA might be within their scope if properly trained and authorized.
D. This scenario involves a side effect of a medication, but it is not a situation requiring an incident report unless it is a severe or unexpected reaction.
Correct Answer is D
Explanation
A. The cause of death is typically determined and documented by the attending physician or coroner, not the nurse.
B.While this information might be included in other parts of the medical record prior to the death, it is not required in postmortem documentation.
C. The nurse should verify that advance directives were followed, but the actual copy of the advance directives does not need to be included in the postmortem documentation. These should already be part of the client’s medical record.
D. Documenting the location of the identification tag is important for proper identification of the body after death. This ensures that the body is correctly identified during transfer to the morgue or funeral home.
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