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 D

Explanation

A) "Turn on overhead lights briefly when checking IV line.": Turning on overhead lights can disrupt the client’s sleep, especially if done during the night. Light exposure can interfere with the body’s natural circadian rhythm, making it harder for the client to fall asleep and stay asleep. A more appropriate action would be to use a dim light or portable light to minimize disturbance.

B) "Open curtains between clients’ semiprivate rooms.": Opening the curtains between semiprivate rooms could increase noise and visual distractions, which may disturb the client's sleep. Keeping the environment as calm and private as possible is essential to reduce stress and promote restful sleep. Curtains should ideally remain closed to promote privacy and minimize distractions.

C) "Conduct change-of-shift report near the clients’ rooms.": Conducting report near the client's rooms can create unnecessary noise and disturb the client’s sleep. The change-of-shift report should ideally take place in a designated area, away from patient rooms, to reduce noise and disturbances in the environment.

D) "Wear shoes with rubber soles.": Wearing shoes with rubber soles reduces noise when walking, which is particularly important in an acute care setting where patients need rest. Quiet movement helps to maintain a peaceful environment, reducing the environmental stressors that can impact sleep quality for clients.

A. Dampened clothes are used for dusting the area B. Waste containers are lined with C. Soiled linens are placed on the floor. D. Uncapped sharps are put in a puncture-resistant container

Correct Answer is C

Explanation

A) Dampened clothes are used for dusting the area: Using dampened clothes for dusting can help minimize the spread of dust and particulate matter in the environment. As long as the cloth is clean and properly disinfected, this action is not typically a source of infection. This is generally a safer approach for cleaning and does not pose an immediate infection risk.

B) Waste containers are lined with: While the phrasing is incomplete, if waste containers are lined properly with appropriate liners and are disposed of regularly, they should not serve as a significant source of infection. Waste disposal is important, but a properly lined container reduces the risk of contamination.

C) Soiled linens are placed on the floor: Placing soiled linens on the floor is a significant source of potential infection for immunocompromised clients. Floors can harbor bacteria, viruses, and other pathogens, and placing soiled linens there increases the likelihood of cross-contamination. The linens should be handled in a way that prevents contact with unclean surfaces to avoid spreading infection.

D) Uncapped sharps are put in a puncture-resistant container: A puncture-resistant container is designed to safely contain sharps such as needles, scalpels, or other sharp objects, minimizing the risk of injury. If sharps are uncapped, however, they could present a risk of needle-stick injury or contamination. However, the main risk comes from improper disposal, not the container itself. Proper disposal in an appropriately designed container is essential to minimizing infection risks.

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

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