A nurse is preparing to perform nasotracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take?
Apply intermittent suction for 20 to 30 seconds.
Place the catheter in a location that is clean and dry for later use.
Hold the suction catheter with the clean, nondominant hand.
Use surgical asepsis when performing the procedure.
The Correct Answer is D
A. "Apply intermittent suction for 20 to 30 seconds." –
Suctioning should be applied intermittently for no more than 10 to 15 seconds to prevent hypoxia and mucosal damage.
B. "Place the catheter in a location that is clean and dry for later use." –
A suction catheter should not be reused once it has been used; it should be discarded after a single use to prevent infection.
C. "Hold the suction catheter with the clean, nondominant hand." –
The dominant hand should remain sterile and be used to control the suction catheter, while the nondominant hand is used to handle nonsterile equipment.
D. "Use surgical asepsis when performing the procedure." –
Nasotracheal suctioning is a sterile procedure because it involves direct access to the lower airway, requiring surgical asepsis to reduce the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Instruct the client to take small sips of water."
Having the client take small sips of water helps the nurse observe the thyroid gland as it moves up and down with swallowing, making abnormalities more noticeable.
B. "Ask the client to hyperextend their neck during palpation."
The client should slightly extend (not hyperextend) their neck to relax the muscles and allow for better palpation of the thyroid gland.
C. "Inspect the isthmus as the client holds their breath for 5 seconds."
The thyroid gland is best observed during swallowing, not by holding the breath.
D. "Assist the client to a supine position prior to the assessment."
Thyroid assessment is performed with the client in a sitting or standing position, not lying down.
Correct Answer is C
Explanation
A. "A client was placed in the waiting room based on their triage assessment." Hospitals can prioritize clients based on triage assessment as long as they receive a medical screening examination and stabilizing treatment if necessary.
B. "A client was transferred to the inpatient antepartum unit to rule out preterm labor." EMTALA requires that hospitals evaluate and stabilize clients with emergency medical conditions, including preterm labor. Transferring a client within the same facility for further evaluation does not violate EMTALA.
C. "A client was referred to the county hospital for medical screening evaluation." Under EMTALA, hospitals must provide a medical screening examination and necessary stabilizing treatment before referring or transferring a client, regardless of their insurance status. Sending a client elsewhere for evaluation without treatment is a violation.
D. "A stable client was transferred to a public hospital that provides reduced-cost care." Once a client has been stabilized, hospitals may arrange for transfer to another facility, provided the transfer meets EMTALA guidelines and is in the client's best interest.
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