A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Check for secretion clearance.
Check the function of the suction catheter.
Don sterile gloves.
Adjust the suction to 120 to 150 mm Hg.
Insert the catheter without suction.
Apply intermittent suction while rotating the catheter
Hyperoxygenate the client.
The Correct Answer is B,C,D,G,E,F,A
Check the function of the suction catheter: Ensures the catheter is functioning properly before starting the procedure.
Don sterile gloves: Maintains asepsis during the suctioning procedure.
Adjust the suction to 120 to 150 mm Hg: Proper suction pressure prevents mucosal trauma.
Hyperoxygenate the client: Prevents hypoxia during the suctioning process.
Insert the catheter without suction: Prevents trauma to mucosa by reducing suction on insertion.
Apply intermittent suction while rotating the catheter: Effectively clears secretions while minimizing tissue damage.
Check for secretion clearance: Ensures the airway is clear and the procedure was effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Clamp the chest tube and place the patient in high Fowler’s position: Clamping the tube may cause tension pneumothorax and should be done only with a specific prescription.
B. Immediately turn the patient to the side of the insertion site: This action does not address the source of constant bubbling.
C. Document findings: Bubbling in the suction chamber can be normal, but documenting without further assessment may overlook potential system issues.
D. Check for air leaks in the drainage system: Constant bubbling may indicate an air leak, which requires immediate assessment and correction.
Correct Answer is D
Explanation
A. Pleural friction rub: An adventitious sound that occurs due to inflamed pleural surfaces rubbing against each other during respiration.
B. Rhonchi: A low-pitched, continuous adventitious lung sound typically caused by airway obstruction or secretions.
C. Stridor: A high-pitched adventitious sound caused by upper airway obstruction.
D. Vesicular: A normal breath sound heard over most of the lung fields, characterized by a soft, low-pitched rustling sound.
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