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 C

Explanation

A) "I should expect my periods to resume in 1 month.": This statement suggests a misunderstanding of the procedure. After a vaginal hysterectomy, periods will not resume because the uterus is removed. If a client expresses such expectations, it may indicate a lack of understanding about the procedure's outcomes and risks, meaning informed consent may not have been adequately given.

B) "I will have a large scar on my stomach after this procedure.": A vaginal hysterectomy is typically performed through the vaginal canal, not requiring an abdominal incision. Therefore, this statement reflects a misunderstanding of the procedure's approach, and would indicate that the client has not been fully informed about the surgical method.

C) "I am thankful I am done having children.": This statement indicates that the client has understood one of the key reasons for having a vaginal hysterectomy. The procedure typically results in the inability to conceive children, which is an important consideration for informed consent. It shows the client is aware of the consequences and is making an informed decision.

D) "I will no longer need regular gynecological examination.": This statement reflects a misunderstanding. Even after a hysterectomy, it’s important for clients to continue routine gynecological exams, as they may still need to monitor other aspects of their reproductive health, including the vagina and ovaries (if retained). It indicates that the client may not have been fully informed about post-operative care requirements.

A. Offer the client several choices at mealtimes B. Remind the client of the day and time often C. Avoid discussing the client's fears D. Alternate daily caregivers.

Correct Answer is B

Explanation

A) Too many choices can be overwhelming and lead to increased frustration or "decision fatigue" for a confused client.

B) Delirium is characterized by an acute, fluctuating change in mental status. Reorientation helps anchor the client to reality and can reduce the anxiety or agitation associated with cognitive clouding.

C) Ignoring a client's fears can increase their sense of isolation and paranoia. Acknowledging feelings while gently correcting misconceptions is more therapeutic.

D) Consistency is key. Frequent changes in staff increase confusion; it is better to have the same nursing team to build familiarity.

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

Nursing Test Bank

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