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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Restlessness can be a common manifestation of pain. When a client is experiencing unrelieved pain, they may exhibit restlessness, which can include fidgeting, pacing, or frequent position changes in an attempt to find relief. Restlessness may also be accompanied by increased heart rate, elevated blood pressure, and changes in respiratory rate.
Difficulty swallowing (dysphagia) is not a specific indicator of unrelieved pain in a client with a spinal epidural for a herniated disc. Difficulty swallowing can be caused by various factors, including anatomical abnormalities, neurological conditions, or muscle dysfunction.
Constipation is not a specific indicator of unrelieved pain in this scenario. Constipation can be a side effect of certain medications, including opioids that are commonly used to manage pain.
However, it is not an exclusive indicator of unrelieved pain and can be managed through interventions such as adequate hydration, fiber intake, and appropriate bowel regimen.
Urinary retention is not a specific indicator of unrelieved pain in this context. It can be associated with several factors, including the use of certain medications, urinary tract infections, or neurological conditions. Urinary retention may require assessment and management but does not necessarily indicate unrelieved pain.
Correct Answer is B
Explanation
A. Incorrect. Plaster casts are not waterproof and can become weakened if exposed to moisture, so showering with the cast is generally not recommended.
B. Correct. Elevating the extremity can help reduce swelling and promote comfort after the cast is applied.
C. Incorrect. Using a hair dryer inside the cast can cause burns and is not recommended for relieving itching.
D. Incorrect. Keeping the cast covered is not necessary, and covering it can trap moisture, potentially causing skin problems.
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