A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

Apply intermittent suction for 30 seconds.

Insert the catheter 10 cm (4 in).

Apply suction while inserting the catheter.

Wait 1 min between suctioning attempts.

Answer and Explanation

The Correct Answer is D

Waiting 1 minute between suctioning attempts allows the client to recover and ensures that the procedure is not overly invasive. It also helps to prevent the client from becoming hypoxic.

The distance that the nasopharyngeal catheter should be inserted varies from person to person and therefore 10 cm is not standard.

During nasopharyngeal suctioning, the nurse should apply suction intermittently while withdrawing the catheter, not during insertion. Applying suction during insertion can cause tissue damage and increase the risk of trauma.

The nurse should also apply intermittent suction for no longer than 15 seconds to prevent hypoxia and damage to the mucosal lining. Suctioning for an extended period can cause discomfort and harm to the client.

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Correct Answer is D

Explanation

Encouraging the client to be assertive is an important aspect of managing dependent personality disorder. It helps the client develop self-confidence, make independent decisions, and advocate for their own needs.

Empowering the client to express their opinions and assert their boundaries can contribute to their personal growth and reduce their reliance on others.

A. A client who has cirrhosis and severe pruritus B. A client who has a femur fracture and reports numbness of the toes C. A client who had a renal biopsy 3 hr ago and has pink-tinged urine D. A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge

Correct Answer is B

Explanation

Numbness of the toes following a femur fracture can indicate potential nerve compromise or damage, which requires immediate attention. Nerve compression or injury can lead to long-term complications if not addressed promptly. It is important for the nurse to assess the client's neurovascular status, including circulation, sensation, and movement, to determine if there is any compromise to the affected limb.

A client with cirrhosis and severe pruritus can be seen next, as pruritus can significantly affect the client's comfort and quality of life. However, it is not immediately life-threatening.

A client who had a renal biopsy 3 hours ago and has pink-tinged urine should be assessed, but this finding is expected after a renal biopsy. The nurse should ensure that the client is monitored for any signs of bleeding or complications, but it may not require immediate attention unless the bleeding worsens or other concerning symptoms arise.

A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge can be seen last, as long as there are no complications or signs of postoperative issues. The nurse should ensure that the client is stable, comfortable, and meeting the necessary criteria for discharge.

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A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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