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 C
Explanation
Ciprofloxacin is a fluoroquinolone antibiotic that can make the skin more sensitive to sunlight, leading to an increased risk of sunburn. It is important for the client to be aware of this potential side effect and take appropriate precautions, such as using sunscreen, wearing protective clothing, and avoiding prolonged sun exposure while taking the medication.
"Take an antacid if the medication causes gastrointestinal upset." Ciprofloxacin should not be taken with antacids or mineral supplements containing calcium, magnesium, aluminum, or iron, as they can interfere with the absorption of the medication. If the client experiences gastrointestinal upset, they should consult their healthcare provider for appropriate management.
"Restrict your daily fluid intake while taking this medication." It is important for the client to maintain adequate hydration while taking ciprofloxacin, as it is important for the elimination of the medication from the body. Restricting fluid intake can lead to dehydration and may affect the effectiveness of the medication. The client should be encouraged to drink plenty of fluids unless otherwise instructed by their healthcare provider.
"Expect to experience diarrhea while taking this medication." While gastrointestinal side effects such as diarrhea can occur with ciprofloxacin, it is not appropriate to state that the client should expect to experience it. Diarrhea can be a sign of a serious adverse reaction, such as Clostridium difficile infection, and should be reported to the healthcare provider for further evaluation and management.
Correct Answer is D
Explanation
A) Incorrect. The knee joint is a hinge joint that allows primarily flexion and extension.
B) Incorrect. The interphalangeal joints are hinge joints that allow primarily flexion and extension of the fingers and toes.
C) Incorrect. The ankle joint is a hinge joint that allows primarily dorsiflexion and plantarflexion of the foot.
D) Correct. The shoulder joint is a classic example of a ball and socket joint, allowing for a wide range of motion in various directions, including flexion, extension, abduction, adduction, rotation, and circumduction.
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