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
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Correct Answer is C
Explanation
A. Incorrect. Elevating the arm might help reduce edema, but the priority is to stop the infusion to prevent further infiltration.
B. Incorrect. While documenting the infiltration is important, immediate action should be taken to stop the infusion to prevent further complications.
C. Correct. The nurse's first action should be to stop the infusion to prevent the continuation of fluid infiltration and potential complications.
D. Incorrect. Applying a warm compress might help with comfort, but stopping the infusion is the priority to prevent further infiltration.
Correct Answer is D
Explanation
A. Incorrect. The Patient Health questionnaire is used to assess depression severity.
B. Incorrect. The Mental Status Examination assesses cognitive function and psychiatric symptoms.
C. Incorrect. The Brief Psychiatric Rating Scale assesses psychiatric symptoms but not specifically tardive dyskinesia.
D. Correct. The Abnormal Involuntary Movement Scale (AIMS. is specifically designed to screen for and assess the severity of tardive dyskinesia, which is a movement disorder associated with antipsychotic medications.
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