Nursing 101 Oxygenation #2 EAQs

A registered nurse teaches a nursing student about suctioning. Which of the nursing student's statements indicates the need for further teaching?

'I should apply negative pressure while inserting the catheter.'

A nurse has difficulty passing the catheter while suctioning a patient. The nurse suspects the reason for this condition is an incomplete opening of the glottis. What is the appropriate intervention?

Advising the patient to cough

A registered nurse instructs a nursing student to apply intermittent suction by placing and releasing the nondominant thumb over the vent of the catheter, and slowly withdrawing the catheter while rotating it back and forth between the dominant thumb and forefinger. What is the rationale behind this intervention?

To prevent injury to the tracheal mucosal lining

The nurse enters the room of a patient who has asthma and observes that the patient requires intermittent suctioning. What is the rationale for this intervention?

To prevent thick, tenacious secretions

A registered nurse explains to a nursing student about the factors to be considered when performing closed suctioning. Which of the nursing student's statements indicates a need for further teaching?

'A new sterile catheter should be used for every suction session.'

A registered nurse teaches a nursing student about suctioning safety guidelines. Which statement if made by the nursing student indicates a need for further education?

'Tracheal suctioning is performed after pharyngeal suctioning.'

The primary health care provider advises the nurse to perform suctioning in a patient who has chronic obstructive pulmonary disorder and who is spontaneously breathing. What nursing action is best in this situation?

Administering oxygen at a rate less than 2 mL/min

Which nursing action is most appropriate during suctioning?

Applying a clean glove to the dominant hand for oropharyngeal suctioning

Which condition may be observed in a patient who receives frequent suctioning?

Arrhythmias

Which nursing intervention is depicted in the image?

Attaching a catheter to a suctioning device

While caring for a patient undergoing suctioning, the nurse guides the catheter along the naris floor to avoid the turbinates. Which outcome observed by the nurse supports the intervention?

Difficulty in passing the suction catheter in the first attempt

Which nursing intervention is appropriate if the nurse observes bloody secretions in the patient while performing suctioning?

Evaluating suctioning frequency and reducing if appropriate

While performing oropharyngeal suctioning, which intervention performed by the registered nurse helps move secretions from the lower to the upper airway and then into the mouth?

Encouraging the patient to cough

The nurse performs nasotracheal suctioning of a patient. The nurse finds that the patient gags and becomes nauseated upon inserting the catheter into the trachea. What should be the response of the nurse?

Gently remove the catheter and wait until the patient breathes normally.

While caring for a patient undergoing suctioning, the nurse suddenly insists on stopping the process of suctioning. Which parameter observed by the nurse supports this intervention?

Heart rate of 40 bpm

Which nursing intervention, if performed before suctioning, minimizes hypoxemia after suctioning?

Hyperoxygenating the patient before suctioning

A registered nurse evaluates the actions of a nursing student who is performing tracheal suctioning in a patient who has a history of respiratory distress. Which of the student's nursing actions indicates effective learning?

Maintaining the suction pressure between 120 and 150 mm Hg while withdrawing the catheter

Which risk is associated with suctioning when performed in an appropriate time interval on a patient who has a head injury?

Increased intracranial pressure

Which type of suctioning should be performed before pharyngeal suctioning?

Nasotracheal suctioning

What is true regarding open suctioning?

Open suctioning involves using a new sterile catheter for each suction session.

Which type of suctioning is used when the patient can cough but is unable to clear the secretions?

Oropharyngeal and nasopharyngeal suctioning

Which statement about oropharyngeal suctioning is true?

Oropharyngeal suctioning is used for a patient who is able to cough effectively.

A patient is undergoing suctioning and experiences a cough, but is unable to manage secretions. Which type of suctioning should occur in this situation?

Orotracheal and nasotracheal suctioning

A registered nurse evaluates the actions of a nurse who is performing endotracheal tube suctioning to a patient with an airway obstruction. Which action made by the nurse is appropriate?

Picking up the suction catheter with the dominant hand

The nurse assesses the clinical findings of four patients as mentioned below. Which patient requires nasotracheal suctioning?

Patient 1 Patient 1 has ineffective airway clearance related to the retained thick pulmonary secretions. Therefore the nurse should perform nasotracheal suctioning. The clinical findings of Patient 2 indicate impaired gas exchange. For this patient, the nurse should administer 2 L/min of oxygen via the nasal cannula and encourage the patient to cough and breathe deeply every hour. Patient 3's findings also indicate impaired gas exchange. The clinical findings of Patient 4 indicate an imbalanced body temperature. To treat this patient, the nurse should administer ordered antipyretics and provide oral fluids.

While performing airway suctioning, the nurse detects that the patient's blood pressure is low and finds that the patient has hypoxemia and arrhythmias. Which nursing action is most likely responsible for the patient's condition?

Performing too frequent suctioning

A child who has a spinal cord injury has difficulty breathing. After suctioning, the child is found to have tracheal edema. Which rationale would best explain this?

Providing deep tracheal suctioning may lead to tracheal edema.

Before nasopharyngeal suctioning, the health care provider assists the patient in taking deep breaths with an oxygen delivery device. What is the rationale behind this action?

To minimize hypoxemia after suctioning

While performing tracheal suctioning, which nursing action is most appropriate in removing secretions adhered to the sides of the endotracheal tube?

Rotating the catheter

A patient with lung disease has difficulty producing a cough. The primary health care provider prescribes chest physiotherapy. After chest physiotherapy, which technique is beneficial for the patient?

Suctioning

What is the advantage of the device that is illustrated in the image?

This device encourages voluntary deep breathing.

The nurse asks a patient to say 'ahh' while performing suctioning. What is the rationale behind this intervention?

To assist in opening the glottis

While performing suctioning, the nurse avoids applying suction pressure while inserting the catheter. What is the rationale behind this?

To avoid traumatizing the lung mucosa

While performing nasotracheal suctioning, the health care provider refrains from applying suction while inserting the catheter. What is the rationale behind this action?

To avoid traumatizing the tracheal mucosa

What is the rationale for hyperventilating the patient who has a head injury prior to suctioning?

To reduce the potential increase in intracranial pressure (ICP)

What type of suctioning involves instilling normal saline and stimulating the patient to cough to loosen airway secretions?

Tracheal suctioning

While performing oropharyngeal suctioning, the nurse needs to assess the patient to determine the frequency of suctioning. Which aspects should the nurse consider? Select all that apply.

Visible secretions Gurgling breath sounds Rhonchi breath sounds

When is it appropriate to use this catheter shown in the image below?

When a patient requires invasive mechanical ventilation