A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

Use medical asepsis when performing the procedure.

Apply suction for 10 seconds.

Advance the catheter 2 cm (0.8 in) after resistance is met.

Withdraw the catheter if the client begins coughing.

Answer and Explanation

The Correct Answer is B

A. Surgical asepsis (sterile technique) should be used for suctioning to prevent infection, not medical asepsis.

B. Applying suction for no longer than 10 seconds is appropriate to prevent hypoxia and trauma to the airway.

C. Advancing the catheter 2 cm after resistance is met is not advised; the catheter should not be forced beyond resistance to avoid injury.

D. The catheter should not be withdrawn if the client begins coughing; instead, it indicates the need for suctioning. If coughing occurs, the nurse should ensure the patient can breathe and may need to suction carefully.

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Correct Answer is C

Explanation

A. The reason for the medication error should not be documented in the client's medical record due to potential legal implications; such information belongs in the incident report instead.

B. Documentation of notification to the pharmacist is relevant for the incident report but is not appropriate for the client's medical record.

C. The time the medication was given is an important detail that should be documented in the client's medical record as it affects the client's treatment and future medication administration.

D. Documenting the completion of the incident report should be done in the facility's quality assurance system, not in the client’s medical record.

A. "I am concerned about my child's future participation in team sports." B. "My child doesn't like to sit still for nebulizer treatments." C. "My child has only a small amount of mucus after percussion therapy." D. "I think that my child has been running a fever over the last couple of days."

Correct Answer is C

Explanation

A. Concerns about participation in team sports are important, but they do not directly warrant a request for a high-frequency chest compression vest.

B. Discomfort with nebulizer treatments suggests the need for alternate therapies but does not specifically indicate a need for the vest.

C. A statement regarding a small amount of mucus after percussion therapy suggests that traditional methods of airway clearance may not be effective enough, indicating a need for a high-frequency chest compression vest to help mobilize mucus.

D. A fever may indicate an infection or exacerbation but does not directly relate to the need for a high-frequency chest compression vest.

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A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

Nursing Test Bank

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