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.
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D. The catheter should not be withdrawn if the client begins coughing; instead, it indicates the need for suctioning.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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Related Questions
Correct Answer is B
Explanation
While a home health nurse visit is important, it is not an immediate safety concern for the client's discharge.
B. The need for assistance when transferring is critical information as it directly impacts the client's safety during discharge; the oncoming nurse must ensure proper support is arranged.
C. The fact that the client's partner will bring clothes is relevant but does not affect the immediate care of the client.
D. Encouragement for personal hygiene is important but is not as urgent as ensuring the client can safely transfer without risk of falls or injury.
Correct Answer is A
Explanation
A. Assisting with deep breathing and coughing is the priority action. This is crucial in preventing respiratory complications, such as atelectasis or pneumonia, especially following abdominal surgery. Deep breathing exercises can help expand the lungs and promote ventilation.
B. Monitoring the incision site for signs of infection is important, but it is not the immediate priority. The client’s respiratory function takes precedence in the early postoperative period.
C. Assessing fluid intake is important for overall recovery, but it is not as critical as ensuring the client can breathe effectively and prevent complications.
D. While ambulation is beneficial for recovery and preventing complications such as deep vein thrombosis, the nurse must first ensure the client can manage their airway and breathing.
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