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 C

Explanation

Proteinuria can indicate kidney dysfunction or potential complications in pregnancy, such as preeclampsia. The provider needs to be aware of this finding and may want to assess the client further and consider appropriate interventions.

The other laboratory values are within normal ranges and do not require immediate reporting. Hgb (hemoglobin) of 13.2 g/dL is within the normal range for pregnancy. BUN (blood urea nitrogen) of 15 mg/dL is within the normal range, indicating normal kidney function. Fasting blood glucose of 72 mg/dL is within the normal range and indicates normal blood sugar levels.

A. You should eat a protein-rich diet during the collection period. B. You should record your blood glucose level each time you void. C. You can begin collection of urine after discarding your first morning void. D. You can cleanse your perineal area with an antiseptic towel each time before you void.

Correct Answer is C

Explanation

C, "You can begin collection of urine after discarding your first morning void."

A 24-hour creatinine clearance test is used to evaluate how well the kidneys are functioning by measuring the amount of creatinine in the blood and urine over a 24-hour period. During the test, the client is asked to discard their first morning void and then collect all urine for the next 24 hours.

Option A is incorrect because a protein-rich diet can aﬀect the creatinine levels in the urine, which can result in inaccurate test results. Therefore, the nurse should advise the client to avoid a protein-rich diet during the collection period.

Option B is incorrect because blood glucose levels are not relevant to a 24-hour creatinine clearance test. Therefore, the nurse should not ask the client to record their blood glucose level each time they void.

Option D is incorrect because using an antiseptic towel to cleanse the perineal area can also aﬀect the test results by introducing contaminants into the urine sample. Therefore, the nurse should advise the client to cleanse the perineal area with soap and water or an alcohol wipe.

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