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 D
Explanation
A. Constipation can be caused by various factors including pain medications, but it is not a direct indicator of unrelieved pain.
B. Difficulty swallowing may not be directly related to unrelieved pain from the herniated disc.
C. Urinary retention is more likely related to the anesthesia effects or nerve compression in the spine rather than unrelieved pain.
D. Correct. Clenched teeth or grimacing are often signs of unrelieved pain. These nonverbal cues can be important indicators of discomfort in patients who might not verbally express their pain.
Correct Answer is B
Explanation
A. Incorrect. Newborns' heads can be sensitive, and washing with a moist towelette might not be gentle enough for their delicate skin.
B. Correct. Newborns' skin is sensitive, and using a warm, wet washcloth without soap is recommended to gently clean their face.
C. Incorrect. Bathing a newborn under a running faucet can be challenging and might expose the baby to temperature variations. It's important to ensure that the baby is comfortable during bathing.
D. Incorrect. Newborns don't need to be bathed daily. Bathing them too frequently can dry out their skin and lead to discomfort.
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