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 C
Explanation
Choice A reason: Applying moist heat to the incision while in bed is not an appropriate instruction, as it can increase the risk of infection, bleeding, or swelling at the site. The nurse should instruct the client to keep the incision dry and covered with a sterile dressing.
Choice B reason: Performing range of motion by adducting the hip is not an appropriate instruction, as it can cause dislocation or damage to the prosthesis. The nurse should instruct the client to avoid crossing their legs or turning their toes inward and to use an abduction pillow or wedge between their legs.
Choice C reason: Sitting in a straight-backed chair is an appropriate instruction, as it can prevent flexion contractures and promote circulation and healing in the hip joint. The nurse should instruct the client to use a raised toilet seat and a chair with armrests and avoid sitting for longer than 45 min at a time.
Choice D reason: Cleansing the surgical incision with hydrogen peroxide is not an appropriate instruction, as it can irritate or damage the tissue and delay wound healing. The nurse should instruct the client to use mild soap and water or saline solution to clean the incision and pat it dry gently.
Correct Answer is D
Explanation
Choice A reason: Discarding soiled wound care supplies in a trash receptacle outside the client's room is not an appropriate action. The nurse should dispose of contaminated materials in a biohazard container inside the client's room to prevent the spread of infection.
Choice B reason: Administering antibiotic therapy before culturing the client's wound is not an appropriate action. The nurse should obtain a wound culture before starting antibiotic therapy to ensure accurate results and avoid altering the microorganisms present in the wound.
Choice C reason: Instructing visitors to perform hand hygiene for 15 seconds after leaving the client's room is not an appropriate action. The nurse should instruct visitors to perform hand hygiene for at least 20 seconds before and after entering the client's room to reduce the risk of transmitting infection.
Choice D reason: Placing the client in a private room with a private bathroom is an appropriate action. The nurse should implement contact precautions for a client who has an infectious wound with foul-smelling drainage to prevent cross-contamination and protect other clients and staff from exposure.
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