Final Exam-Skills Lab

The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions for this procedure? Select all that apply. A. Keeping a supply of suction catheters at the bedside B. Auscultating breath sounds to determine the need for suctioning C. Hyperoxygenating the client before, during, and after suctioning D. Intermittently suctioning during insertion of the suction catheter E. Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed

A,B,C. Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is used. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently, to determine if suctioning is needed. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. Intermittent suction should be applied while the catheter is being withdrawn, not while it is being inserted. Suctioning should not be performed for longer than 10 seconds at one time to prevent cerebral hypoxia and a rise in intracranial pressure.

The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction? A. Suctioning the client every hour B. Applying suction only during withdrawal of the catheter C. Hyperventilating the client with 100% oxygen before suctioning D. Applying suction intermittently during withdrawal of the catheter

A. The client should be suctioned as needed. Unnecessary suctioning should be avoided because it can increase secretions and cause mechanical trauma to the tissues. The client should be hyperoxygenated with 100% oxygen before suctioning. Suction is not applied during insertion of the catheter; intermittent suction and a twirling motion of the catheter are used during withdrawal.

The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action? A. Hyperoxygenate the client. B. Set the suction pressure range at 150 mm Hg. C. Place the catheter into the tracheostomy tube. D. Apply suction on the catheter, and insert it into the tracheostomy tube.

A. The nurse should hyperoxygenate the client both before and after suctioning. This would be the initial nursing action. The safe suction range for an adult client is 80 to 120 mm Hg. When the nurse advances the catheter into the tracheostomy tube, suction is not applied because applying suction at that time will cause mucosal trauma and aspiration of the client's oxygen.

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? A. 1.5 seconds B. 10 seconds C. 30 seconds D. 60 seconds

B. Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.

A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status? A. Oxygen saturation of 89% B. Respiratory rate of 16 breaths/minute C. Moderate amounts of tracheobronchial secretions D. Small to moderate amounts of frank blood suctioned from the tube

B. Impaired gas exchange could occur after tracheostomy because of excessive secretions, bleeding into the trachea, restricted lung expansion because of immobility, or concurrent respiratory conditions. An oxygen saturation of 89% is less than optimal. A respiratory rate of 16 breaths/minute is in the normal range.

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate A. Continue to suction. B. Notify the health care provider immediately. C. Stop the procedure and reoxygenate the client. D. Ensure that the suction is limited to 15 seconds.

C. During suctioning, the nurse should monitor the client closely for adverse effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. Which co-existing condition in the client may cause an inaccurate pulse oximetry reading? A. Fever B. Epilepsy C. Hypotension D. Respiratory failure

C. Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings as a result of impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low.

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? A.Dilate the major bronchi. B.Increase surfactant production. C.Maintain inflation of the alveoli. D.Enhance ciliary action in the tracheobronchial tree.

C. Sustained inhalation when using an incentive spirometer helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not benefits for sustained inhalation.