Nokea
The nurse is performing nasotracheal suctioning of a client. What should the nurse do when suctioning this client?
- A. Apply suction for 5-10 seconds.
- B. Plan to suction for 10 minutes.
- C. Apply suction while inserting the catheter.
- D. Apply suction for 20-30 seconds.
Correct Answer: A
Rationale: Nasotracheal suctioning should apply suction for 5-10 seconds (A) to minimize hypoxia and trauma with intermittent suctioning. Suctioning for 10 minutes (B) is excessive and dangerous. Applying suction during insertion (C) risks mucosal damage. 20-30 seconds (D) is too long increasing hypoxia risk making A the correct technique.
You may also like to solve these questions
A client who has endometrial cancer is receiving sealed internal radiation therapy. Which actions should the nurse implement? Select one that doesn't apply.
- A. Wear a lead apron when providing care.
- B. Remove soiled dressings from the room.
- C. Instruct visitors to wear a dosimeter badge.
- D. Place dislodged source in biohazard container.
Correct Answer: C
Rationale: 1. Wearing a lead apron when providing care is recommended to protect the caregiver from radiation exposure. Always keep the front of the apron facing the client and do not turn so that the back of the caregiver is facing the client. 5. Women who are pregnant (including caregivers) should not enter the room. In addition, if the caregiver is attempting to conceive, whether they are male or female, they should not perform direct client care. Children younger than 16 should not be allowed to visit either. A 'Caution: Radioactive Material' sign should be placed on the door to the client’s room.
A nurse is caring for a patient with a tracheostomy. What is the priority intervention?
- A. Monitor oxygen saturation
- B. Clean the site
- C. Suction as needed
- D. Change the dressing
Correct Answer: C
Rationale: Suctioning as needed maintains airway patency in a tracheostomy, ensuring oxygenation, taking priority over monitoring, cleaning, or dressing changes.
A client who was a victim of a house fire is coughing. The nurse realizes that the purpose of the cough is to
- A. improve oxygenation.
- B. remove irritants from the nasal passages.
- C. remove irritants from the trachea or bronchi.
- D. close the glottis.
Correct Answer: C
Rationale: Coughing removes irritants from the trachea and bronchi (C) where mucus traps particles and cilia sweep them upward. It does not primarily improve oxygenation (A) or involve nasal passages (B). Closing the glottis (D) is unrelated to cough function making C the correct purpose especially relevant after smoke inhalation.
The nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client’s vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
- A. Document the provider’s statement in the medical record
- B. Complete an incident report
- C. Consult the facility’s risk manager
- D. Notify the nursing manager.
Correct Answer: D
Rationale: Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status, therefore the next action is to activate the chain of command to ensure the client receives care.
Which term refers to the exchange of oxygen and carbon dioxide at the alveolar level?
- A. Ventilation
- B. Perfusion
- C. Diffusion
- D. Respiration
Correct Answer: C
Rationale: Diffusion is the process where oxygen moves from alveoli to blood and carbon dioxide moves from blood to alveoli, occurring at the alveolar-capillary membrane.