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.
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Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
The nurse should identify that emotional dysregulation and fear of abandonment indicate manifestations of borderline personality disorder. Emotional dysregulation is a hallmark of borderline personality disorder (BPD), characterized by intense and rapidly shifting emotions. Fear of abandonment is a core feature of BPD, leading to anxiety and distress over perceived or anticipated rejection by significant others.
A. Tactile hallucinations: Tactile hallucinations refer to false perceptions of touch or physical sensations on the skin, which are not typically associated with borderline personality disorder. These hallucinations are more commonly associated with conditions like schizophrenia or substance-induced disorders.
B. Emotional ability: Emotional dysregulation is a hallmark of borderline personality disorder (BPD). Individuals with BPD often experience intense and rapidly shifting emotions that can be triggered by seemingly minor events. This emotional volatility can lead to difficulties in interpersonal relationships and impulsive behaviors.
C. Fear of abandonment: Fear of abandonment is a core feature of borderline personality disorder. Individuals with BPD often experience intense anxiety and distress when they perceive or anticipate rejection or abandonment by significant others. This fear can drive their behaviors, including efforts to prevent real or imagined abandonment.
D. Elevated body temperature: Elevated body temperature is not a characteristic manifestation of borderline personality disorder. Instead, it may be associated with medical conditions such as infections or inflammatory processes.
E. Increased heart: While emotional distress and anxiety are common in individuals with borderline personality disorder, "increased heart" is not a specific manifestation of the disorder. Anxiety and emotional distress can lead to physiological responses such as increased heart rate, but this is a general response rather than a defining characteristic of BPD.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
The client likely suffered from intoxication as evidenced by hypokinesia.
Intoxication from substances such as opioids can lead to a range of symptoms including sedation and altered mental status. In this case, the presence of a needle in the antecubital space and the administration of naloxone suggest opioid use.
Hypokinesia, characterized by reduced movement, aligns with the symptoms observed in opioid intoxication, such as decreased responsiveness and drowsiness. The historical pattern of sedation, miosis (constricted pupils), and mood alteration further supports the diagnosis of intoxication as the underlying condition.
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