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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.Maintain low-level lights in common areas.Inadequate lighting can contribute to disorientation and falls. Well-lit areas with natural or soft lighting are preferable.
B.Give the client several meal options at lunchtime.Too many choices can be overwhelming and increase confusion. Instead, limiting choices (e.g., offering just two meal options) is a better approach.
C.Confront the client regarding inappropriate behavior.Confrontation can increase agitation and distress. Instead, redirection and gentle guidance are more effective strategies.
D. Use symbols in the communal room signage.Clients experiencing confusion and memory loss benefit from visual cues and simple, clear communication. Using symbols (such as pictures of a toilet for the restroom or a plate for the dining area) can help them navigate the environment more easily and reduce frustration.
Correct Answer is ["B","C","D"]
Explanation
It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without further assessment and evidence.
Asking the client's child to provide details regarding the client's fractured arm will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.
Discussing respite care options with the client's child may help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.
Speaking to the client privately will help establish trust and rapport, and allow the client to disclose any
concerns or issues that they may not feel comfortable sharing in front of their child.
Providing legal advice regarding power of attorney is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of attorney should be assessed before providing such advice.
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