A nurse is preparing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

Wait 1 min between 1 suctioning attempts

Apply intermittent suction for 30 seconds

Insert the catheter 10 cm (4 in.)

Apply suction while inserting the catheter.

Answer and Explanation

The Correct Answer is C

A) Wait 1 min between suctioning attempts: The nurse should wait 20 to 30 seconds between suctioning attempts, not a full minute. Waiting too long between attempts can cause the patient unnecessary distress. The goal is to allow for oxygenation and recovery of the airway in between suctioning attempts.

B) Apply intermittent suction for 30 seconds: Suctioning should be limited to 10 to 15 seconds at a time to prevent hypoxia and damage to the mucous membranes. Applying suction for 30 seconds could lead to complications such as hypoxia, mucosal trauma, and increased risk of infection.

C) Insert the catheter 10 cm (4 in.): This is the correct technique. For an adult client, the catheter should be inserted 10 cm (4 inches) into the airway. Inserting the catheter too far can cause trauma to the airway, while inserting it too shallow may not effectively clear secretions.

D) Apply suction while inserting the catheter: Suction should not be applied while inserting the catheter. Suctioning should only be applied while withdrawing the catheter, not while inserting it, to prevent mucosal trauma and to ensure effective clearance of secretions. Suctioning during insertion could damage the airway and increase discomfort for the client.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Condition: Opioid intoxication – The client's presentation of unresponsiveness, respiratory depression (RR 10/min), and miosis (pinpoint pupils) is consistent with opioid intoxication. Additionally, the presence of a needle in the antecubital space suggests recent intravenous drug use.

Finding: Pupil characteristics – Opioid intoxication commonly causes miosis (pinpoint pupils), which was observed in the client.

A. Put small cushion under the newborn's head for support. B. Position the car seat at a 90° angle. C. Place the shoulder harnesses at the level of the infant's shoulders. D. Keep the airbag on if the car seat is in the front seat.

Correct Answer is C

Explanation

A) "Put small cushion under the newborn's head for support.":
This statement is incorrect. Placing a small cushion or any additional padding under a newborn’s head in a car seat is not recommended. Extra padding can interfere with the proper fit of the harness and could pose a safety risk in the event of a crash. The car seat should be used as designed, without extra padding that could affect the infant's positioning.

B) "Position the car seat at a 90° angle.":
This statement is incorrect. The car seat should be positioned at a 45-degree angle, not 90 degrees. A 45-degree angle helps prevent the infant’s head from falling forward, which can obstruct the airway and cause breathing difficulties. Positioning the seat at the correct angle ensures that the baby’s head and neck are properly supported.

C) "Place the shoulder harnesses at the level of the infant's shoulders.":
This statement is correct. For optimal safety, the shoulder harness straps should be at or just below the infant's shoulders when they are in a rear-facing car seat. This positioning helps to keep the baby secure and ensures the harness fits properly in the event of an accident. The harness should be snug and positioned correctly to provide the best protection.

D) "Keep the airbag on if the car seat is in the front seat.":
This statement is incorrect. It is recommended that infants and young children always be placed in a rear-facing car seat in the back seat of the vehicle, as this is the safest position. Airbags can be dangerous to infants if the car seat is in the front seat. If the car seat must be placed in the front seat (which is not recommended), the airbag should be turned off to prevent injury in the event of a crash.

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Body system	Findings
Head. Eyes. Ears. Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendancies Insomnia
Genitourinary	Darkening of the urine Urinary frequency

A nurse is preparing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of client. Drag 1 condition and 1 finding to fill in each blank in the following sentences The client likely suffered from ____ as evidenced by ____ .

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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