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A nurse in the PACU is performing oral suctioning for a patient with an oropharyngeal airway, when the patient begins to vomit. What is the nurse's priority nursing action at this time?
- A. Removing the suction catheter and elevating the head of the bed
- B. Notifying the primary health care provider
- C. Confirming the size of the oral airway is correct
- D. Placing the patient in the supine position
Correct Answer: A
Rationale: The nurse discontinues suctioning, elevates the head of the bed, and turns the patient to the side to prevent aspiration. Airway protection takes priority; after positioning the patient, the nurse continues to suction the airway and oropharynx. Once airway patency has been established, the nurse will notify the provider of vomiting. There is no indication the oral airway is too large. Placing the patient supine while vomiting is inappropriate, as that could promote aspiration.
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A nurse working in the pulmonary clinic is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend?
- A. Avoid exercise.
- B. Take steps to manage or reduce anxiety.
- C. Eat meals 1 to 2 hours prior to breathing treatments.
- D. Eat a high-protein/high-calorie diet.
- E. Maintain a high-Fowler position when possible.
- F. Drink 2 to 3 pints of clear fluids daily.
Correct Answer: B,D,E
Rationale: When caring for patients with COPD, it is important to help create an environment that is likely to reduce anxiety, which increases oxygen demand. A high-protein/high-calorie diet is recommended to meet increased energy needs due to the work of breathing. People with dyspnea and orthopnea are most comfortable in a high-Fowler (upright) position because accessory muscles can easily be used to facilitate respiration and lung expansion. Meals should be eaten 1 to 2 hours after breathing treatments; exercise and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended, rather than 2 to 3 pints.
A nurse is teaching a patient how to use a metered-dose inhaler for asthma. Which comments from the patient assure the nurse that the teaching has been effective?
- A. I'll be careful not to shake the canister before using it.
- B. It's important to hold the canister upside down when using it.
- C. I have to remember to inhale the medication through my nose.
- D. I will continue to inhale when the cold propellant is in my throat.
- E. I won't inhale more than one spray with one breath.
- F. I will activate the device while continuing to inhale.
Correct Answer: D,E,F
Rationale: Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, inhaling two sprays with one breath, and not activating the device while inhaling.
A nurse plans to suction a patient's endotracheal tube using the open suction technique. Which intervention is appropriate for this technique?
- A. Using a suction catheter that is the diameter of the endotracheal tube
- B. Maintaining the patient in the supine position
- C. Administering oxygen prior to suctioning
- D. Changing the inline suction device every 24 hours
Correct Answer: C
Rationale: To prevent hypoxemia, prior to endotracheal suctioning, the nurse provides 100% oxygen for a minimum of 30 seconds. This is referred to as hyperoxygenation. The nurse limits the application of suction to no more than 10 to 15 seconds. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. An inline suction device is considered a closed, self-contained system used for a 'closed technique' for suction; these are changed every 24 hours.
A nurse is planning to suction a patient's tracheostomy tube the day after its placement. Which action by the nurse is absolutely essential?
- A. Assessing the need to premedicate with an analgesic
- B. Placing the patient in low Fowler position
- C. Inserting the obturator into the outer cannula
- D. Maintaining aseptic technique
Correct Answer: D
Rationale: Sterile technique is used for tracheal suctioning, to reduce the risk of introduction of disease-causing organisms. Aseptic technique is imperative to avoid introducing organisms into the lower airway. An obturator, which guides the direction of the outer cannula, is inserted into the tube during placement and removed once the outer cannula of the tube is in place. In the home setting, clean technique is used.
A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident?
- A. Instructing the assistant to notify the health care team
- B. Assessing the patient's vital signs
- C. Removing the tape, adjusting the depth to the ordered depth, and retaping securely
- D. Taking no action, as the depth will adjust automatically
Correct Answer: C
Rationale: The tube depth should be maintained at the same level unless otherwise prescribed. If the depth changes, the nurse should remove the tape or securement device, adjust the tube to the ordered depth, and reapply the tape or securement device.