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.
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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Related Questions
Correct Answer is D
Explanation
A. Maintain low-level lights in common areas.Low-level lighting can increase confusion and the risk of falls, especially for clients with memory loss. It is important to have adequate lighting to promote a safe environment and help with orientation. Well-lit areas can reduce disorientation and anxiety in clients who are confused or have memory issues.
B. Give the client several meal options at lunchtime. For clients with memory loss and confusion, it is better to provide simple choices or pre-selected meals to reduce decision-making stress and confusion.
C. Confront the client regarding inappropriate behavior.Confronting a client with memory loss or confusion about inappropriate behavior can increase agitation, anxiety, and defensive reactions.
D. Use symbols in the communal room signage.Symbols and pictures can help clients with memory loss navigate their environment more easily because they may have difficulty reading or comprehending written language. Visual cues such as symbols in signage can improve orientation and independence, helping the client feel more comfortable in their surroundings.
Correct Answer is C
Explanation
a.Ferrous sulfateworks best when you take it on an empty stomach. However, taking ferrous sulfate on an empty stomach can actually increase the risk of gastrointestinal side effects, such as nausea. It is often recommended to take it with food to reduce nausea, even though absorption is best on an empty stomach. Thus, this statement does not indicate proper understanding.
b.Black stools are a common side effect of taking iron supplements and are usually not a cause for concern unless they are tarry or associated with other symptoms, which could indicate gastrointestinal bleeding. Reporting black stools to the doctor is typically not necessary unless the stool is tarry and has other concerning symptoms like abdominal pain or bleeding. This statement reflects a misunderstanding of common side effects.
c.Mixing ferrous sulfate elixir with a full glass of water is advisable because it helps dilute the medication, making it easier to swallow and reducing the risk of gastrointestinal irritation. This practice also ensures that the medication is taken completely. This statement indicates a correct understanding of how to take the medication properly.
d.While staying hydrated can help manage constipation, milk is not recommended with iron supplements because calcium in milk can interfere with the absorption of iron. Instead, increasing water intake, eating a high-fiber diet, and considering other dietary measures would be better advice for preventing constipation.
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