Elsevier: Respiratory Care and Suctioning

A. Adhere to sterile technique when appropriate.

2. How can the nurse best minimize a patient's risk for infection during tracheostomy care? A. Adhere to sterile technique when appropriate. B. Frequently assess for signs of local or systemic infection. C. Monitor for indications that tracheostomy care is needed. D. Instruct nursing assistive personnel (NAP) to report any changes in color or odor of tracheal drainage.

B. Comparing respiratory assessment data from before and after the suctioning procedure.

2. How does the nurse evaluate the effect of nasotracheal suctioning on a patient's respiratory status? A. Asking the patient about symptoms of respiratory difficulty. B. Comparing respiratory assessment data from before and after the suctioning procedure. C. Confirming that the patient's pulse oximetry value is >90%. D. Auscultating the patient's chest after suctioning.

B. To ensure that the catheter's suction is functioning properly

2. When preparing to suction a patient's oral cavity, why would the nurse first suction a small amount of sterile water through the catheter? A. To moisten the exterior of the plastic catheter B. To ensure that the catheter's suction is functioning properly C. To minimize friction as the catheter moves within the oral cavity D. To avoid startling the patient with the sound created by the suction

B. Remove the catheter.

3. As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, "I feel like I'm going to throw up." What is the nurse's best response? A. Complete the catheter insertion in 5 seconds or less. B. Remove the catheter. C. Encourage the patient to take several deep breaths to minimize the nausea. D. Stop advancing the catheter, and allow the patient to rest for several minutes.

B. Keep the oxygen mask near the patient's face during the suctioning procedure.

3. What is a priority intervention when performing oropharyngeal suctioning for a patient who is receiving oxygen by face mask? A. Complete the suctioning process in 20 seconds or less. B. Keep the oxygen mask near the patient's face during the suctioning procedure. C. Encourage the patient to take several deep breaths before suctioning begins. D. Increase the oxygen flow rate by 1 L/min for 3 minutes before suctioning.

B. Cleaning and assessing the skin around the stoma

3. Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? A. Cleaning the stoma with hydrogen peroxide and drying thoroughly B. Cleaning and assessing the skin around the stoma C. Assessing temperature and reporting skin breakdown immediately D. Allowing the patient to re-oxygenate after each tracheal suctioning

A. Place the Yankauer catheter in a clean, dry area.

4. After oropharyngeal suctioning, what does the nurse do with the supplies? A. Place the Yankauer catheter in a clean, dry area. B. Place all disposable equipment into the wrapper of the suction catheter before discarding it in a trash receptacle. C. Fold the paper drape with the outer surface inward, and dispose of it in a biohazard receptacle. D. Place dirty gloves in the biohazard receptacle in the patient's room.

D. Place water-soluble lubricant onto the open sterile catheter package.

4. Which action is part of the preparation for nasotracheal suctioning? A. Place the patient in a supine position. B. Preoxygenate the patient with 100% oxygen. C. Suction 100 mL of warm tap water to flush the suction catheter. D. Place water-soluble lubricant onto the open sterile catheter package.

B. Ensure that two fingers fit snugly under the tie.

4. Which technique would the nurse use to change a patient's tracheostomy ties? A. Use a slipknot. B. Ensure that two fingers fit snugly under the tie. C. Knot the ends of the tie in the eyelets on the faceplate. D. Ask the patient to hold his or her breath while the ties are changed.

A. Comparing presuctioning and postsuctioning respiratory assessment data

5. Which action is most useful in evaluating the effectiveness of oropharyngeal suctioning? A. Comparing presuctioning and postsuctioning respiratory assessment data B. Confirming that the patient's pulse oximetry value is >90% C. Asking the patient to report any symptoms of dyspnea D. Assessing the patient's skin for signs of cyanosis

B. Place the patient in a semi-Fowler's or sitting position.

Which action would the nurse perform when preparing to suction a patient's oropharynx? A. Apply sterile gloves. B. Place the patient in a semi-Fowler's or sitting position. C. Remove the nasal cannula. D. Flush the suction catheter with 200 mL of warm tap water.

B. Keeping an obturator and a tracheostomy tube at the patient's bedside

Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? A. Having a spare oxygen mask at the patient's bedside B. Keeping an obturator and a tracheostomy tube at the patient's bedside C. Reviewing the agency's policy regarding tracheostomy care D. Instructing the family to call immediately if the patient has difficulty breathing

C. Holding the tracheostomy tube while the nurse changes the neck ties

5. Which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy? A. Performing tracheostomy care for a patient whose tracheostomy was placed 1 week ago B. Removing the outer cannula and placing the obturator C. Holding the tracheostomy tube while the nurse changes the neck ties D. Monitoring oxygen saturation levels and placing oxygen if needed

C. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88%.

5. Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning? A. Patient complains of discomfort during the procedure. B. Patient has a severe bout of nonproductive coughing and complains of sore throat. C. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88%. D. Patient's pulse rate increases by 10 bpm.

C. Discontinue suctioning by removing the suction catheter.

While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has fallen from 102 bpm to 80 bpm. What is the best course of action? A. Encourage the patient to take several deep breaths. B. Interrupt suction to the catheter for at least 10 seconds. C. Discontinue suctioning by removing the suction catheter. D. Assess the patient's pulse oximetry reading to see if oxygenation is adequate.