Module 17 Quiz

The nurse is suctioning a client with a tracheostomy using an open system device. Which action will the nurse implement specifically to help prevent trauma to the tracheal tissue? a) Hyperventilate the client prior to beginning the procedure. b) Limit the number of suction passes to three. c) Apply suction at 110 to 130 mm Hg from the wall unit. d) Maintain strict aseptic technique during the procedure.

Apply suction at 110 to 130 mm Hg from the wall unit. To help prevent trauma to the tracheal tissues, the nurse should apply suction at 110 to 130 mm Hg from a wall unit or 10 to 15 cm on a portable unit. Using higher pressures when suctioning via a tracheostomy can cause trauma to the tracheal tissue. The nurse limits the number of suction passes and hyperventilates the client prior to the procedure to help prevent hypoxemia during the procedure, not to prevent trauma to the tissues. The nurse maintains strict aseptic technique to help prevent infection, not to prevent trauma to the tissues.

The nurse is suctioning a client's tracheostomy using an open system. For which action should the nurse use the gloved, dominant hand? a) connecting the suction tubing to the suction catheter b) controlling the suction valve on the catheter c) manipulating the suction catheter d) hyperventilating the client with a manual resuscitation bag

manipulating the suction catheter When suctioning a tracheostomy, the gloved, dominant hand remains sterile and is used to manipulate and handle the suction catheter. The gloved, nondominant hand is used to control the suction valve, connect the suction tubing to the suction catheter, and hyperventilate the client with a manual resuscitation bag.

The nurse is preparing to suction a client who has a tracheostomy after cardiac surgery. To help minimize the client's anxiety, which statement made by the nurse is most therapeutic? a) "I've done this procedure many times and it has not caused a great amount of pain in any of my clients." b) "Once the procedure is started, we will not interrupt it so that we do not cause additional pain." c) "Try to relax a little; the more anxious you are, the more pain you will experience." d) "If you experience any difficulty, squeeze my hand and I will stop to allow you to rest a bit."

"If you experience any difficulty, squeeze my hand and I will stop to allow you to rest a bit." The most therapeutic response by the nurse is "If you experience any difficulty, squeeze my hand and I will stop to allow you to rest a bit." This statement puts the client in control by allowing the client to signal the nurse to stop at any time by squeezing the nurse's hand. The nurse should also explain the procedure to alleviate the client's fears, since any procedure that compromises respiration can be frightening to the client. Stating that the nurse has done this many times and describing how other clients reacted to it does not treat this client as an individual. These statements also do not show understanding that all clients are individuals and can experience pain and anxiety very differently. Stating that the client will experience more pain if the client does not relax is likely to make the client more anxious and fearful. Telling the client that once started, the nurse will not stop the procedure takes all control away from the client.

Place in order, from first to last, the actions the nurse will perform when preparing to suction an alert client via tracheostomy using an open system. Use all options.

1. Explain the procedure to the client. 2. Adjust the bed and position the client. 3. Adjust the wall suction to the appropriate level. 4. Open sterile packages and set up sterile field. 5. Don sterile gloves. 6. Auscultate the client's lung sounds for evaluation of the intervention. When preparing to suction a client, of the actions listed, the nurse should first explain the procedure to the client, then adjust the bed to a good working height and position the client in a semi-fowler's position. Then, the nurse should adjust the wall suction and connect the suction tubing ensuring the connecting end is within easy reach. Next, the nurse should open sterile packages using aseptic technique and set up the sterile field. The nurse should then don sterile gloves and perform the procedure. After the procedure, the nurse should auscultate the client's lung sounds to evaluate if the intervention was effective.

Place in order, from first to last, the actions the nurse will perform when suctioning a client using a closed system suction. Use all options.

1. Explain the procedure to the client. 2. Turn on the suction at the wall unit. 3. Grasp the suction catheter through the protective sheath. 4. Withdraw the catheter while applying intermittent suction. 5. Assess the client's respiratory status for improvement. The nurse should first explain the procedure to the client, assist client to comfortable position, and then turn the suction on at the wall unit and attach the tubing. Next, the nurse should grasp the catheter through the protective sheath and slowly advance the catheter without suction. The nurse should then slowly withdraw the catheter using intermittent suction to remove secretions from the airway. Once the procedure is completed, the nurse should assess the client's respiratory status to evaluate effectiveness of the intervention.

The nurse is changing a disposable inner cannula on a tracheostomy client, Place in order, from first to last, the actions the nurse will perform. Use all options.

1. Open supplies using aseptic technique. 2. Remove oxygen source to tracheostomy if present. 3. Use nondominant hand to stabilize the outer cannula and faceplate. 4. Remove inner cannula and site dressing and place them in disposable bag. 5. Remove and discard clean gloves, and put on sterile gloves. 6. Use dominant hand to pick up the new inner cannula, and insert it into the outer cannula. First, the nurse should open all supplies using aseptic technique and prepare the sterile field. Next, the nurse should remove the oxygen source, if one is present; this action would not be performed first, because the client should continue to receive the oxygen during the preparations. After removing the oxygen source, the nurse should stabilize the outer cannula and faceplate of the tracheostomy with the nondominant hand. Then, using the dominant hand, the nurse should grasp the locking mechanism of the inner cannula and gently remove the inner cannula and site dressing, placing them in the previously prepared disposable bag. Working quickly, the nurse should then discard the current clean gloves and put on sterile gloves. Once sterile gloves are donned, the nurse should pick up the new inner cannula with the dominant hand; stabilize the faceplate with the nondominant hand, and gently insert the new inner cannula into the outer cannula. Finally, the nurse should press the tabs to allow the lock to grab the outer cannula and reapply the oxygen source, if needed.

After assessing clients with a tracheostomy, which client will the nurse suction? a) A client with a diminished gag reflex because of stroke. b) A client with an oxygen saturation of 97% via pulse oximetry. c) A client who has not been suctioned in more than 4 hours. d) A client with rhonchi in upper airways noted on auscultation.

A client with rhonchi in upper airways noted on auscultation. The nurse should only suction when assessment findings indicate a need to suction. Rhonchi noted on assessment indicate the client needs to be suctioned to clear the airway. Limiting suctioning to only when assessment findings indicate the need helps to minimize potential trauma to the mucosa. Adventitious breath sounds (secretions, rhonchi, rales) indicate a need to suction to clear the airway. Failure to recognize the indications and the need to clear the client's airway will diminish the client's oxygen saturation. An oxygen saturation of 97% is well within the desired range and does not indicate a need to suction. Suction should never be scheduled or done just because it has not been done in 4 hours; it should only be done when assessment findings indicate a need. Diminished gag reflex is not remedied by suctioning.

The nurse is preparing to provide tracheostomy care to a client with a new tracheostomy. Which action should the nurse take before beginning the procedure? a) Assess the client for pain and administer analgesic as needed. b) Apply a topical analgesic around the tracheostomy stoma site. c) Ensure that any oxygen source is tightly secured to the tracheostomy. d) Hyperventilate the client with a manual resuscitation bag.

Assess the client for pain and administer analgesic as needed. Before beginning the procedure, the nurse should assess the client for pain or discomfort and administer the prescribed analgesic if indicated. Hyperventilating the client is done with suctioning, not with tracheostomy care. Analgesics are not applied to the stoma site. Any oxygen source would need to be removed to perform tracheostomy care.

The nurse has just finished suctioning a client with a tracheostomy. Which action should the nurse take next? a) Ask the client if any pain medication is needed. b) Document the procedure and client tolerance. c) Assess the client's lung sounds. d) Remind the client to use the call bell when needed.

Assess the client's lung sounds. Upon completion of the procedure, the nurse would reassess the client's respiratory status, including respiratory rate, effort, oxygen saturation, and lung sounds. This determines the effectiveness of the suctioning and the presence of any complications. This is the evaluation step of the nursing process. Asking about the need for pain medication should have happened before the procedure. The nurse cannot document the procedure until effectiveness has been documented and respiratory status reassessed. While reminding the client to use the call bell is important, this would not be the nurses next step. It should be done before the nurse leaves the client's room.

After changing the disposable inner cannula and changing the dressing of a client who has a tracheostomy, a nurse prepares to change the client's tracheostomy collar. Which action would the nurse take first? a) Enlist the assistance of a second nurse. b) Pull the first hook-and-loop fastener strap out of the opening on the faceplate. c) Keep the old collar in place until the new collar is secured. d) Ask the client to take a deep breath and remove the collar in one piece.

Enlist the assistance of a second nurse. The nurse changing a tracheostomy collar would first enlist the assistance of a second nurse to hold the tracheostomy in place during the procedure. The primary nurse would then unfasten one hook-and-loop fastener strip from the faceplate and remove it from behind the client's neck. The nurse would then remove the second hook-and-loop fastener strip and the soiled collar, and then replace it with a new one.

The nurse is providing tracheostomy care to a client and is preparing to change the client's tracheostomy collar. Which action would be most appropriate? a) Enlist the help of a second nurse to hold the tracheostomy tube in place while the old collar is removed and the new collar is placed. b) Enlist the help of two other nurses, one to stabilize the client's neck and the other to hold the tube in place during the process. c) Check the fit of the tracheostomy collar after applying it, confirming that three fingers can be inserted between the neck and the collar. d) Hold the tracheostomy tube in place with the nondominant hand while changing the collar with the dominant hand.

Enlist the help of a second nurse to hold the tracheostomy tube in place while the old collar is removed and the new collar is placed. The nurse changing the tracheostomy collar should enlist the help of a second nurse to hold the tracheostomy tube in place while the old collar is removed and the new collar is applied. Holding the tracheostomy tube in place ensures that the tracheostomy will not inadvertently be expelled if the client coughs or moves. The nurse would check the fit of the collar after applying it, confirming that one finger can be inserted between the neck and the collar. This permits neck flexion that is comfortable and ensures that the collar will not compromise circulation to the area.

When suctioning a client with a tracheostomy using an open system, which actions by the nurse would help to prevent hypoxemia during the procedure? Select all that apply. a) Hyperventilate the client with 3 to 6 breaths before suctioning. b) Use sterile saline to clear the suction tubing. c) Maintain sterile technique at all times during the procedure. d) Limit suctioning to 10 to 15 seconds each time. e) Pause for 30 to 60 seconds between suctioning attempts.

Hyperventilate the client with 3 to 6 breaths before suctioning. Limit suctioning to 10 to 15 seconds each time. Pause for 30 to 60 seconds between suctioning attempts. To reduce the risk of hypoxemia, the nurse would pause for 30 to 60 seconds between suctioning attempts, limit suctioning to 10 to 15 seconds each time, and hyperventilate the client with 3 to 6 breaths before suctioning. Maintaining sterile technique and using sterile saline to clear the tubing prevents the accidental introduction of pathogens, but do not prevent hypoxemia.

The nurse has just finished replacing a disposable inner cannula of a client's tracheostomy. The client begins coughing and dislodges the tracheostomy. Which action should the nurse take first? a) Insert the obturator into a new tracheostomy and insert the tracheostomy into the stoma. b) Notify the health care provider. c) Rinse off the expelled tracheostomy with sterile saline and reinsert it using the obturator. d) Replace the collar on the expelled tracheostomy and reinsert it using the obturator.

Insert the obturator into a new tracheostomy and insert the tracheostomy into the stoma. To maintain aseptic technique, the nurse should insert the obturator into a new, sterile tracheostomy and insert the tracheostomy into the stoma. The nurse need not notify the health care provider, unless the tracheostomy is not easily reinserted. Neither simply rinsing off the expelled tracheostomy nor replacing its collar and then reinserting it would maintain aseptic technique, as the tracheostomy became unsterile upon being expelled.

The nurse has assessed a client with a tracheostomy and decided that suctioning is needed. Which action will the nurse implement to help prevent complications? a) Allow a 2-minute interval between suctioning passes. b) Suction the mouth first, and then insert the catheter in the tracheostomy. c) Suction the trachea only after suctioning the oropharynx. d) Limit suctioning passes to no more than three per episode.

Limit suctioning passes to no more than three per episode. When suctioning a client, the nurse should not attempt more than three suctioning passes per episode, because excessive suction passes can cause hypoxemia and contribute to other complications. The nurse need only allow a 30-second to 1-minute interval between suctioning to allow for reventilation and reoxygenation of airways. The trachea is considered sterile and therefore should be suctioned first, before the oropharynx or mouth. Suctioning the oropharynx or mouth first contaminates the suction catheter and risks introducing pathogens into the trachea.

On assessment, the nurse notes significant secretions on the client's tracheostomy dressing. The health care provider's prescription states that tracheostomy site care is to be done once per shift. The nurse has already performed site care once during the current shift. What is the best action by the nurse? a) Request that the nurse on the next shift change the dressing. b) Notify the health care provider and request additional prescription. c) Perform site care again and document the procedure. d) Wipe the secretions off the dressing as best as possible.

Perform site care again and document the procedure. The best action by the nurse is to perform the needed site care again and document the procedure. The prescription for site care once per shift indicates the minimum frequency for the procedure. The nurse uses his or her judgement to determine if and when it needs to be done more than once a shift. Failure to change the dressing puts the client at risk of infection and skin breakdown. There is no need to notify the health care provider, because it is within the nurse's scope of practice to make the judgement that the dressing needs to be changed and site care performed in order to prevent harm to the client. Postponing the site care by requesting that it be performed by the nurse on the next shift places the client at risk of infection and skin breakdown. Simply wiping the secretions off the dressing will not remove all the potential pathogens.

The nurse is providing tracheostomy care for a client and cleans the nondisposable inner cannula with the brush. What should the nurse do next? a) Apply a water-based lubricant to the inner cannula. b) Dry the inner cannula with a sterile, precut gauze. c) Agitate the inner cannula in a basin of hydrogen peroxide. d) Place the inner cannula in a basin of sterile saline.

Place the inner cannula in a basin of sterile saline. After cleaning the inner cannula with the brush, the nurse should place the cannula in a basin of sterile saline and agitate it to rinse the cannula thoroughly. The nurse should then remove the cannula from the saline, tap it against the inner edge of the basin to remove excess fluid, and place it on a sterile gauze to dry. The nurse should not use a sterile precut gauze to dry the cannula after cleaning it with the brush, because, at this point, the cannula has not yet been rinsed. The nurse should use sterile saline, not hydrogen peroxide, at this point of the procedure. The peroxide is to be used before cleaning the inner cannula with the brush. Lubricants are not used on the inner cannula.

The nurse if providing tracheostomy care to a client with a nondisposable inner cannula. Which action should the nurse take next after removing the inner cannula? a) Place the inner cannula in a sterile alcohol solution to soak. b) Use a pipe cleaner and sterile saline to clean the lumen of the inner cannula. c) Replace the client's oxygen source over the outer cannula. d) Suction the client using sterile technique.

Replace the client's oxygen source over the outer cannula. After removing the inner cannula the nurse should next replace the client's oxygen source over the outer cannula to provide the needed oxygen supplementation and to help prevent a decline in oxygen saturation. The nurse should soak nondisposable inner cannula in a basin of hydrogen peroxide or half hydrogen peroxide and half sterile saline, based on the facility's policy but it should never be placed in alcohol for cleaning. After replacing the oxygen source, the nurse can proceed with the procedure and clean the cannula with the pipe cleaner and saline. The nurse should have performed any needed suctioning before beginning the tracheostomy care.

On assessment, the nurse notes that the tracheostomy ties are grossly soiled and require changing. No one is available to assist at this time. What is the best action by the nurse? a) Instruct the client in the importance of not coughing during the procedure. b) Secure the new tracheostomy ties before removing the old ties. c) Wait until later when someone is available to assist with the change. d) Remove the soiled ties and tape the tracheostomy collar securely in place.

Secure the new tracheostomy ties before removing the old ties. The best action by the nurse at this time is to change the ties by first securing the new ties and then removing the old ties. Delaying care until someone is available places the client at risk of infection from the grossly soiled ties. Taping the collar is not an appropriate action, because secretions will cause the tape to loosen. Tracheostomy care can cause the client to need to cough, so this would not be a proper instruction. The client may not be able to help but cough, and this may dislodge the cannula if the trach is not secured with ties or being held in place by a second person.

When suctioning the tracheostomy, when would the nurse suction the oral cavity? a) Just prior to suctioning the tracheostomy. b) 1 to 2 hours after suctioning the tracheostomy. c) Shortly after suctioning the tracheostomy. d) Simultaneously while suctioning the tracheostomy.

Shortly after suctioning the tracheostomy. The oral cavity would be suctioned with a separate single-use, disposable catheter following the suctioning of the tracheostomy. In addition, the nurse would perform oral hygiene for the client. Suctioning of the oral cavity removes secretions that are stagnant in the mouth and pharynx, reducing the risk of infection.

The nurse is providing site care for a client with a tracheostomy using a nondisposable inner cannula. Which step is recommended to release the lock on the device? a) Stabilize the outer cannula and faceplate with the nondominant hand. b) Rotate the inner cannula counter-clockwise using the nondominant hand. c.) Stabilize the outer cannula and faceplate with the dominant hand. d) Rotate the inner cannula clockwise using the dominant hand.

Stabilize the outer cannula and faceplate with the nondominant hand. The nurse opening the lock on a tracheostomy would stabilize the outer cannula and faceplate using the nondominant hand and rotate the inner cannula counter-clockwise with the dominant hand. This action unlocks the outer cannula and releases the nondisposable inner cannula so that it can be cleaned.

While providing care to a client who has a tracheostomy with a nondisposable inner cannula, the nurse observes secretions that have accumulated in the outer cannula. Which action would the nurse take? a) Suction the outer cannula using strict aseptic technique. b) Gently clean the outer cannula with the brush used to clean the inner cannula. c) Wipe the secretions away with a tissue. d) Encourage the client to cough up the secretions.

Suction the outer cannula using strict aseptic technique. If secretions have accumulated in the outer cannula during cleaning of the inner cannula, the nurse should suction the outer cannula using aseptic technique. The brush used to clean the inner cannula is now contaminated and should not be inserted into the outer cannula. Encouraging the client to cough may dislodge the outer cannula. Wiping away the secretions with a tissue could introduce fibers and, possibly, organisms into the client's respiratory tract.

The nurse is observing a family caregiver doing a return demonstration of tracheostomy care for a client with a nondisposable inner cannula. Which action by the family caregiver indicates that additional teaching is required? a) The family caregiver agitates the inner cannula in a basin of sterile saline after cleaning it with the brush. b) The family caregiver raises the bed to the caregiver's elbow level and raises the head of the bed to semi-Fowler's. c) The family caregiver performs hand hygiene, then dons clean gloves and a face shield to begin the procedure. d) The family caregiver rotates the inner cannula clockwise with the nondominant hand to release the lock.

The family caregiver rotates the inner cannula clockwise with the nondominant hand to release the lock. Further teaching is indicated when the caregiver rotates the inner cannula clockwise with the nondominant hand to release the lock. The caregiver should be taught to use the dominant hand to turn the inner cannula counter clockwise to release the lock. The following actions by the caregiver are all correct and appropriate: raising the bed to the caregiver's elbow level and the head of the bed to semi-Fowler's; performing hand hygiene, donning clean gloves and a face shield to begin the procedure; and agitating the inner cannula in a basin of sterile saline after cleaning it with the brush.

The nurse is providing tracheostomy care for a client. When changing the dressing, which action would be most appropriate for cleaning the stoma? a) Allow the skin to air dry for 30 seconds before applying the dressing. b) Use each applicator only once, moving from the stoma site outward. c) Clean the faceplate avoiding the area around the stoma. d) Dip a cotton-tipped applicator into a cup of sterile water.

Use each applicator only once, moving from the stoma site outward. When cleaning the stoma while changing the dressing of a tracheostomy, the nurse would clean the stoma using each applicator only once, moving from the stoma site outward. The nurse would dip the cotton-tipped applicator in a cup of sterile saline, not water. The nurse would pat the skin gently using a 4 × 4 gauze sponge prior to applying the new dressing. Saline is nonirritating to tissue and the gauze removes excess moisture. Cleansing outward and using each applicator only once adheres to aseptic technique.

The nurse is preparing to provide tracheostomy care to a client. The client's tracheostomy dressing is soiled, but a commercially prepared tracheostomy dressing is not available. Which action should the nurse perform? a) Use two folded gauze sponges on each side of the stoma. b) Cut a small slit in a sterile gauze pad. c) Wait until a commercially prepared dressing becomes available. d) Apply water-soluble lubricant around the stoma.

Use two folded gauze sponges on each side of the stoma. If a commercially prepared tracheostomy dressing is not available, the nurse should fold two gauze sponges on the diagonal to form triangles; the nurse should then slide one triangle under the faceplate on each side of the stoma, with the longest side of the triangle against the tracheostomy. Waiting for a commercially prepared dressing would be inappropriate, because the client's dressing is soiled and needs to be changed to reduce the risk of infection. Cutting a gauze pad can create loose fibers, which can become lodged in the stoma and cause irritation or infection. Loose fibers could also be inhaled into the trachea and cause respiratory distress. Water-soluble lubricant is not used around the stoma.

While suctioning a client, the nurse inserts a closed-system suction catheter into the tracheostomy tube and meets resistance. Which action should the nurse take? a) Remove the catheter and notify the health care provider. b) Withdraw the catheter at least 0.5 in (1.25 cm) before applying suction. c) Insert saline into the port to clean the catheter and advance the tubing again. d) Remove the catheter and insert a new one.

Withdraw the catheter at least 0.5 in (1.25 cm) before applying suction. If the nurse meets resistance, the carina or tracheal mucosa has been hit. The nurse would withdraw the catheter at least 0.5 in (1.25 cm) before applying suction. In this situation, the catheter does not need to be removed or changed, and the health care provider does not need to be called. To clean the catheter between suctioning passes, saline is inserted into the port prior to inserting the suction catheter.

The nurse is inserting the suction catheter into a client's tracheostomy and suddenly meets resistance. Which action would be most appropriate? a) Rotate the catheter one half-turn. b) Apply suction to the catheter. c) Withdraw the catheter at least 0.5 in (1.25 cm). d) Continue inserting the catheter another inch (2.5 cm).

Withdraw the catheter at least 0.5 in (1.25 cm). If resistance is met when inserting the suction catheter, the carina or tracheal mucosa has been hit. Therefore, the nurse should withdraw the catheter at least 0.5 in (1.25 cm) before applying suction. Continuing to insert the catheter, applying suction or rotating the catheter is inappropriate at this time.

When providing tracheostomy care to a client with a disposable inner cannula, at which point would the nurse put on sterile gloves? a) after opening the cotton-tipped applicators b) after removing the old inner cannula c) before filling the sterile cup with saline d) before opening the package containing the new cannula

after removing the old inner cannula Sterile gloves are put on after the inner cannula is removed and discarded, just before the nurse picks up the new inner cannula whose package was opened previously. Gloves do not need to be worn when opening the package for the new cannula, opening the cotton-tipped applicators, or filling the sterile cup with saline.

Which client is most likely to need administration of pain medication before being suctioned via the tracheostomy? a) client who had abdominal surgery b) client with bilateral pneumonia c) client who had a toe amputation d) client with diabetes mellitus

client who had abdominal surgery The client who had abdominal surgery is most likely to require the administration of pain medication before being suctioned. Suctioning will likely cause the client to cough; coughing requires the use of the abdominal muscles, which can be painful after surgery in that area. While any client may need pain medication before suctioning, the conditions of diabetes mellitus, a toe amputation, and bilateral pneumonia are less likely than abdominal surgery to cause pain when coughing. Clients with these conditions are thus less likely to need pain medication before suctioning via a tracheostomy.

After changing a client's tracheostomy holder, the nurse determines that the collar fits properly when: a) the client can flex the neck comfortably. b) two fingers fit under the holder. c) the hook-and-loop fastener tabs are adhered together. d) the faceplate is centered.

the client can flex the neck comfortably. A tracheostomy holder fits properly when the nurse can insert one finger between the neck and the holder to allow the client to flex the neck comfortably. Neither adherence of the tabs nor a centered faceplate ensures that the holder is properly fitted.

The nurse is preparing to suction the tracheostomy of a client. The nurse would place which client in the lateral position, facing the nurse? a) unconscious client, after abdominal surgery b) client who is confused or uncooperative c) conscious client, who has had hip surgery d) conscious teenager with trauma to the trachea

unconscious client, after abdominal surgery The lateral position is used for clients who are unconscious, because this position prevents the airway from becoming obstructed and promotes drainage of secretions. The other client examples would be placed in the semi-Fowler's position, which helps the client to cough and makes breathing easier. The nurse would use interventions to calm a client who is confused or uncooperative prior to suctioning the tracheostomy.

The nurse is observing a student nurse suction a client with a tracheostomy using an open system. Which action by the student nurse will require additional instruction by the nurse? The student nurse: a) uses the nondominant hand to connect the suction tubing to the suction catheter. b) uses a manual resuscitation bag to give the client 2 big breaths before beginning. c) pauses for 45 seconds between suction attempts and encourages the client to cough. d) adjusts the wall suction to 130 mm Hg on a wall unit.

uses a manual resuscitation bag to give the client 2 big breaths before beginning. Additional instruction would be needed when the student nurse only gives the client 2 breaths to hyperventilate him or her before the procedure. The student nurse should deliver 3 to 6 breaths to hyperventilate the client, which helps in preventing hypoxemia during the procedure. Adjusting the wall suction to 130 mm Hg on a wall unit, using the nondominant hand to connect the suction tubing to the suction catheter, and pausing for 30 to 60 seconds between suction attempts and encouraging the client to cough are all appropriate actions.

When preparing to suction a client's tracheostomy, which action by the nurse best helps to prevent the introduction of microorganisms into the respiratory tract? a) applying suction only during insertion of the suction catheter b) using only the dominant hand to handle and manipulate the catheter c) using the dominant hand to open and close the suction port d) gently rotating the suction catheter as it is being withdrawn

using only the dominant hand to handle and manipulate the catheter The nurse should use the dominant hand to control and manipulate the suction catheter, keeping the dominant hand sterile during the procedure to prevent accidentally introducing microorganisms into the respiratory tract. Gently rotating the suction catheter is done to facilitate the removal of secretions and is not related to preventing infection. Suction should only be applied while slowly removing the suction catheter, not during insertion. Moreover, suctioning is done to remove secretions and clear the client's airway, not to prevent the introduction of microorganisms. The nurse should use the thumb of the nondominant hand, which is considered clean, but not sterile, to open and close the suction port.