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":"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.
Correct Answer is D
Explanation
A. Incorrect. While monitoring dietary potassium might be relevant for some clients on certain medications, it is not the primary action for addressing syncope related to enalapril.
B. Incorrect. Withholding the medication based solely on pulse rate is not an appropriate action.
The nurse should provide guidance on appropriate management.
C. Incorrect. Decreasing daily fluid intake is not likely to address the syncope related to enalapril.
D. Correct. Enalapril is an ACE inhibitor, and syncope can be a side effect due to changes in blood pressure. Advising the client to rise slowly from a sitting position can help prevent sudden drops in blood pressure and decrease the risk of syncope.
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