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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Incorrect. Dry mucous membranes are not typically associated with hyperkalemia.
B. Correct. Hyperkalemia can lead to cardiac dysrhythmias, including irregular heart rate.
C. Incorrect. Hyperactive reflexes are more commonly associated with hypokalemia (low potassium levels.
D. Incorrect. Trousseau's sign is a clinical indicator of hypocalcemia, not hyperkalemia.

A. Urine output of 300 ml over 8 hr. B. Occasional small clots in the urine C. Dark red urine D. Frequent urge to urinate

Correct Answer is C

Explanation

A. Incorrect. A urine output of 300 ml over 8 hours is within the expected range for a postoperative client and does not require immediate reporting.
B. Incorrect. Occasional small clots in the urine are common in the immediate postoperative period following a transurethral resection of the prostate and do not necessarily require immediate reporting.
C. Correct. Dark red urine can indicate bleeding and may be a sign of hemorrhage. This finding should be reported to the provider for further assessment and intervention.
D. Incorrect. A frequent urge to urinate is expected following a transurethral resection of the prostate, as irritation and swelling can occur in the immediate postoperative period.

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A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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