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: Performing breast exams every other month is not an adequate frequency, as it can delay the detection of any changes or abnormalities. The client should perform breast exams monthly, preferably a few days after their period ends.
Choice B reason: Having one breast larger than the other is a common variation and not a cause for concern, unless there is a sudden change in size or shape. The client should be aware of their normal breast appearance and report any changes to their provider.
Choice C reason: Performing breast exams the day their period begins is not an optimal time, as their breasts may be swollen, tender, or lumpy due to hormonal fluctuations. The client should perform breast exams when their breasts are not affected by their menstrual cycle, such as a week after their period ends.
Choice D reason: Having skin dimpling on their breasts is not a common variation and may indicate an underlying tumor that pulls on the connective tissue and causes puckering of the skin. The client should inspect their breasts for any changes in skin texture, such as dimpling, peau d'orange, or redness, and report them to their provider.
Correct Answer is C
Explanation
Choice C Hemoglobin 8.6 g/dL indicates the nurse should notify the provider because it is below the normal range of 12 to 18 g/dL and suggests blood loss or anemia, which can impair oxygen delivery to tissues and affect wound healing.
Choice a is not correct because blood glucose 98 mg/dL does not indicate the nurse should notify the provider because it is within the normal range of 70 to 110 mg/dL and does not indicate hyperglycemia or hypoglycemia, which can affect recovery.
Choice b is not correct because BUN 18 mg/dL does not indicate the nurse should notify the provider because it is within the normal range of 10 to 20 mg/dL and does not indicate renal impairment or dehydration, which can affect fluid and electrolyte balance.
Choice d is not correct because potassium 3.5 mEq/L does not indicate the nurse should notify the provider because it is within the normal range of 3.5 to 5 mEq/L and does not indicate hypokalemia or hyperkalemia, which can affect cardiac function and muscle contraction.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today