A nurse is reinforcing discharge teaching with the partner of a client who requires tracheal suctioning. Which of the following statements by the partner indicates an understanding of the teaching?
"I will wrap the suction catheters in a clean towel to be used again at a later time."
"I will set the suction pressure dial between 80 and 120."
"I will suction for less than 15 seconds while inserting the suction catheter."
"I will suction the mouth before inserting the suction catheter into the tracheostomy."
The Correct Answer is B
Choice A Reason:
The statement “I will wrap the suction catheters in a clean towel to be used again at a later time” is incorrect. Suction catheters should be disposed of after each use to prevent infection. Reusing catheters, even if wrapped in a clean towel, can introduce bacteria into the tracheostomy site, leading to potential infections.
Choice B Reason:
The statement “I will set the suction pressure dial between 80 and 120” is correct. The recommended suction pressure for adults is typically between 80 and 120 mmHg. This range is sufficient to effectively clear secretions without causing trauma to the tracheal mucosa. Setting the suction pressure within this range ensures safe and effective suctioning.
Choice C Reason:
The statement “I will suction for less than 15 seconds while inserting the suction catheter” is incorrect. Suctioning should be performed intermittently and for no longer than 10-15 seconds at a time. However, suctioning should not occur while inserting the catheter. Suction should be applied only while withdrawing the catheter to minimize trauma to the tracheal mucosa.
Choice D Reason:
The statement “I will suction the mouth before inserting the suction catheter into the tracheostomy” is incorrect. Suctioning the mouth before the tracheostomy can introduce oral bacteria into the tracheostomy site, increasing the risk of infection. The correct procedure is to suction the tracheostomy first and then the mouth if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The thigh-high stockings should reach just below the gluteal folds, not above them. If the stockings are too high, they can cause constriction and impair circulation.
Choice B reason: Reapplying the stockings before getting out of bed is an appropriate action. The client should remove the stockings at night and inspect the skin for any signs of irritation or breakdown. The client should also elevate the legs for 15 minutes before putting on the stockings to reduce edema and improve venous return.
Choice C reason: Flexing the toes when applying the stockings is not an appropriate action. The client should point the toes and foot downward when applying the stockings to prevent wrinkles or folds that can cause pressure ulcers.
Choice D reason: Rolling down knee-high stockings slightly to provide comfort is not an appropriate action. The client should avoid rolling or folding the stockings as this can create a tourniquet effect and impair blood flow.
Correct Answer is A
Explanation
Choice A reason: Wearing an N95 mask when in the client's room is an appropriate instruction, as it can protect the AP from inhaling airborne droplets that contain pertussis bacteria, which can cause a highly contagious respiratory infection.
Choice B reason: Wearing a gown when caring for the client is not necessary, as pertussis is not transmitted by contact with body fluids or surfaces.
Choice C reason: Wearing a simple face mask when caring for the client is not sufficient, as it does not filter out small particles that can carry pertussis bacteria and enter the respiratory tract.
Choice D reason: Placing the client in a negative air pressure room is not indicated, as pertussis is not classified as an airborne infection that requires isolation in a specially ventilated room.
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