Nokea
A nurse is maintaining airway patency in an unconscious patient by providing frequent nasopharyngeal suction. When would the nurse anticipate inserting a nasopharyngeal airway (nasal trumpet)?
- A. Vomiting during suctioning occurs.
- B. Secretions appear to contain stomach contents.
- C. The suction catheter touches an unsterile surface.
- D. Epistaxis is noted with continued suctioning.
Correct Answer: D
Rationale: Repeated suctioning may injure or traumatize the nares, resulting in nosebleed (epistaxis). The nurse would recommend insertion of a nasal trumpet, which will facilitate suction while protecting the nasal mucosa from further trauma.
You may also like to solve these questions
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 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.
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.
Which assessments and interventions should the nurse consider when performing tracheal suctioning?
- A. Closely assessing the patient before, during, and after the procedure
- B. Hyperoxygenating the patient before and after suctioning
- C. Limiting the application of suction to 20 to 30 seconds
- D. Monitoring the pulse to detect effects of hypoxia and stimulation of the vagus nerve
- E. Using an appropriate suction pressure (80 to 150 mm Hg)
- F. Inserting the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube
Correct Answer: A,B,D,E,F
Rationale: Close assessment of the patient before, during, and after the procedure is necessary to identify complications such as hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. In addition, monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis caused by excessive negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage.
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.