To assess lung sounds.

Choice A rationale:

Sterile suctioning is not performed to administer medications. Its primary purpose is to remove secretions and maintain a patent airway.

Choice B rationale:

Sterile suctioning is not done solely for promoting comfort. Its main goal is to clear the airway and prevent respiratory complications.

Choice C rationale:

The purpose of sterile suctioning is to assess lung sounds by removing excess secretions and mucus that may obstruct the airway. This helps in evaluating the patient's respiratory status and identifying any abnormal lung sounds.

Choice D rationale:

Sterile suctioning is not performed to monitor vital signs. Although vital signs may be monitored during the procedure, it is not the primary purpose of suctioning.

Choice A:

Plastic,.

Choice B:

Metal,.

Choice C:

Silicone, and Choice D:

Rubber.

Choice A rationale:

Plastic suctioning catheters are commonly used for sterile suctioning as they are disposable and come in various sizes for different patient needs.

Choice B rationale:

Metal suctioning catheters are also used for sterile suctioning and are often reusable, making them cost-effective for healthcare facilities.

Choice C rationale:

Silicone suctioning catheters are commonly used in sensitive situations or patients with latex allergies, as silicone is a non-allergenic material.

Choice D rationale:

Rubber suctioning catheters were commonly used in the past, but they are less common now due to the availability of more suitable materials like plastic and silicone.

Choice E rationale:

Glass suctioning catheters are not used for sterile suctioning due to the risk of breakage, which can lead to serious injuries and complications.

"I have been coughing up blood.”.

Choice A rationale:

Mild nasal congestion may be a common finding in many patients and does not necessarily contraindicate suctioning unless it significantly obstructs the airway.

Choice B rationale:

A sore throat may indicate local irritation, but it does not directly contraindicate suctioning unless there are other underlying complications.

Choice C rationale:

A history of coughing up blood (hemoptysis) suggests an ongoing bleeding disorder. Suctioning could exacerbate the bleeding, leading to further complications. The procedure should be avoided until the cause of hemoptysis is properly assessed and managed.

Choice D rationale:

Feeling lightheaded may be a common sensation during and after suctioning due to the stimulation of the gag reflex, but it does not necessarily contraindicate the procedure. It is essential to ensure adequate oxygenation and provide proper support during the procedure to minimize this discomfort.

Choice A rationale:

Epiglottitis is an inflammation of the epiglottis, which is a crucial structure in protecting the airway during swallowing. Suctioning in patients with a history of epiglottitis can be dangerous because it can cause further irritation and swelling of the epiglottis, potentially leading to airway obstruction and respiratory distress. Therefore, sterile suctioning is contraindicated in patients with a history of epiglottitis.

Choice B rationale:

Laryngeal edema refers to swelling of the larynx, which can also compromise the airway. While it is essential to monitor and manage laryngeal edema carefully, it is not an absolute contraindication for sterile suctioning. In some cases, suctioning may be necessary to maintain a patent airway, but it should be performed with caution and by experienced personnel.

Choice C rationale:

Difficulty clearing secretions is a common indication for sterile suctioning. Patients who have difficulty clearing their secretions may need suctioning to prevent the accumulation of mucus and maintain a clear airway. Therefore, this statement does not indicate a contraindication for the procedure.

Choice D rationale:

Using an artificial airway at night, such as a tracheostomy tube, indicates that the patient may require suctioning to maintain airway patency. While having an artificial airway increases the risk of infection and other complications, it is not a contraindication for sterile suctioning if clinically indicated.

Choice A rationale:

The most crucial measure to prevent cross-contamination during sterile suctioning is the use of personal protective equipment (PPE). PPE, including gloves, gown, mask, and eye protection, creates a barrier between the healthcare provider and the patient's respiratory secretions, reducing the risk of infection transmission.

Choice B rationale:

Proper disposal of waste materials is important for infection control, but it is not the most critical measure to prevent cross-contamination during sterile suctioning. While proper waste disposal is necessary to reduce the spread of infections, using PPE is more directly related to preventing cross-contamination during the procedure.

Choice C rationale:

Environmental cleaning of the suction device is essential for infection control, but it is not the most important measure to prevent cross-contamination during sterile suctioning. The immediate and direct protection provided by PPE is more effective in reducing the risk of transmission during the procedure.

Choice D rationale:

Performing hand hygiene before and after the procedure is vital for infection control, but it is not the most crucial measure to prevent cross-contamination during sterile suctioning. While hand hygiene is essential for reducing the spread of infections, using PPE provides an additional layer of protection during the procedure.

Choice D rationale:

When suctioning patients with an artificial airway, using disposable plastic catheters is preferred to reduce the risk of infection. Disposable catheters are single-use and discarded after each procedure, minimizing the potential for contamination and cross-infection between patients.

Choice A rationale:

Glass suctioning catheters are not preferred because they cannot be effectively sterilized for reuse. Reusable materials carry a higher risk of infection transmission and should be avoided when possible.

Choice B rationale:

Metal suctioning catheters are also not the preferred choice for reducing the risk of infection. Like glass catheters, they can be difficult to clean and sterilize adequately for safe reuse. Using disposable materials, like plastic catheters, is a safer option.

Choice C rationale:

While reusable silicone catheters may be more flexible and gentler on the airway, they are not the preferred choice for infection control. Like other reusable materials, they carry a higher risk of contamination and are not as easily disposed of as disposable plastic catheters.

Choice A rationale:

A closed catheter is the most appropriate choice for suctioning a patient with thick secretions. Closed catheters have a two-way valve that allows for continuous suction while minimizing the risk of introducing air into the patient's airway. This design prevents the loss of oxygen and maintains a closed system, reducing the risk of complications such as hypoxia and infection.

Choice B rationale:

Metal catheters are not suitable for suctioning thick secretions. They can be rigid and may cause trauma to the airway, leading to bleeding and discomfort for the patient.

Choice C rationale:

Large French scale catheters are not specifically designed for thick secretions and may not effectively aspirate them. These catheters are typically used for drainage of body cavities or larger organs.

Choice D rationale:

A catheter with a single opening is not ideal for suctioning thick secretions. It may not provide sufficient suctioning power and could lead to ineffective removal of secretions from the patient's airway.

Choice A rationale:

Environmental cleaning before suctioning is crucial to maintain a clean and safe environment for the patient. This reduces the risk of introducing additional contaminants during the procedure.

Choice B rationale:

Using a reusable suctioning catheter is not appropriate for infection control measures. Reusable catheters can harbor microorganisms, even after proper cleaning and sterilization, increasing the risk of cross-contamination.

Choice C rationale:

Proper disposal of used catheters into a regular trash bin is not a suitable infection control measure. Used catheters should be disposed of in designated biohazard containers to prevent exposure to potential pathogens.

Choice D rationale:

Hand hygiene before and after the procedure is essential to reduce the transmission of microorganisms to and from the patient.

Choice E rationale:

Wearing gloves and a mask during suctioning helps protect the nurse from exposure to the patient's bodily fluids and potential infectious agents.

Repeat steps 7 to 9 until no more secretions are obtained or until three passes are completed. Do not suction more than three times in a row to prevent complications. Allow at least one minute of rest between each suction pass to prevent fatigue and distress .

Choice A rationale:

Donning personal protective equipment (PPE) is the priority action before performing sterile suctioning. This helps prevent the transmission of infection from patient to nurse and vice versa.

Choice B rationale:

Preoxygenating the patient with 100% oxygen is essential before nasopharyngeal suctioning, but the priority action is to ensure the nurse's safety by using PPE.

Choice C rationale:

Obtaining baseline data on vital signs and secretions is an important step, but it can be done after the nurse has ensured their safety with appropriate PPE.

Choice D rationale:

Inserting the catheter into the artificial airway using sterile technique is part of the procedure but should be preceded by wearing proper PPE to maintain a sterile environment.

Choice A rationale:

The nurse should not rotate the catheter between the thumb and forefinger during suctioning. This action could cause trauma to the airway.

Choice B rationale:

Limiting each suction pass to no more than 10 seconds is an essential practice during sterile suctioning. Prolonged suctioning can lead to hypoxia and potential complications.

Choice C rationale:

Rinsing the catheter and tubing with saline after each suction pass helps maintain patency and prevent the accumulation of secretions, ensuring effective suctioning during the procedure.

Choice D rationale:

Applying continuous suction while inserting the catheter is not recommended during sterile suctioning. Intermittent suction is preferred for safety and effectiveness.

Choice E rationale:

Providing encouragement and support to the client throughout the procedure is crucial for their comfort and cooperation. Suctioning can be uncomfortable, and the client may need reassurance during the process.

Choice A rationale:

(Incorrect) Stating that it's common for oxygen saturation to drop during suctioning is not appropriate because a drop in oxygen saturation is an abnormal response that requires immediate intervention.

Choice B rationale:

(Incorrect) Telling the patient that a drop in oxygen levels is a normal response and will improve soon is incorrect and may lead to delay in addressing the potential respiratory distress.

Choice C rationale:

(Correct) This response is appropriate because the nurse should stop suctioning immediately if the patient's oxygen saturation drops below the normal range and provide supplemental oxygen to maintain adequate oxygenation.

Choice D rationale:

(Incorrect) Advising the patient to take slow deep breaths to increase oxygen levels may not be sufficient to address the oxygen saturation drop, which requires immediate intervention.

Choice A rationale:

(Incorrect) Assuring the client that the procedure is entirely safe is not entirely accurate, as suctioning can carry some risks and discomfort.

Choice B rationale:

(Correct) This response acknowledges the client's concern about the suctioning procedure while providing a rationale for its importance, which is to maintain clear airways and prevent complications like airway blockage and respiratory distress.

Choice C rationale:

(Incorrect) Stating that there are no other options to remove secretions may not be true, and it does not address the client's concern effectively.

Choice D rationale:

(Incorrect) Promising to suction quickly may not address the client's worry and might compromise the effectiveness of the procedure, as thorough suctioning is necessary.

Choice A rationale:

(Correct) After sterile suctioning, it is essential to reposition the patient to a comfortable and safe position, ensuring proper alignment and support to prevent complications.

Choice B rationale:

(Incorrect) While documentation is crucial, ensuring the patient's safety and comfort should be the immediate priority after the procedure.

Choice C rationale:

(Incorrect) The nurse should not remove the catheter and tubing from the artificial airway immediately after suctioning, as it may still be needed for subsequent interventions.

Choice D rationale:

(Incorrect) Assessing the patient's response to suctioning is essential, but ensuring safety and repositioning take precedence immediately after the procedure.

Choice A rationale:

The nurse should indeed provide reassurance and answer any questions before performing any procedure, as this helps to alleviate the patient's anxiety and ensure they are well-informed about the procedure.

Choice B rationale:

Gathering the necessary equipment and supplies is essential before starting sterile suctioning. This ensures that the nurse has everything needed for the procedure, promoting efficiency and safety.

Choice C rationale:

Connecting the suction tubing to the suction device is an important step in the suctioning process, but it should be done after gathering all the necessary equipment and supplies.

Choice D rationale:

Preoxygenating the patient with 100% oxygen is not a step required before suctioning. Preoxygenation may be necessary before some procedures, but it is not specifically indicated for sterile suctioning.

Choice A rationale:

Continuing suctioning when the patient is experiencing bronchospasm and increased intracranial pressure can worsen their condition and potentially lead to further complications. It is not appropriate to continue suctioning in this situation.

Choice B rationale:

Adjusting the pressure on the suction device may not be sufficient to address the patient's current condition. Stopping suctioning and providing appropriate interventions are more crucial in this situation.

Choice C rationale:

Stopping suctioning immediately is the most appropriate action when the patient experiences bronchospasm and increased intracranial pressure. The nurse should assess the patient's airway, administer bronchodilators or other prescribed treatments as needed, and seek medical assistance if necessary.

Choice D rationale:

Increasing the suction pass time is not recommended as it can exacerbate the patient's condition and lead to complications. The focus should be on stopping suctioning and providing appropriate interventions.

Choice A rationale:

Rinsing the catheter and tubing with saline after each suction pass is not a standard practice and is not necessary for sterile suctioning.

Choice B rationale:

Inserting the catheter into the artificial airway using sterile technique is crucial to maintain the integrity of the procedure and prevent infections.

Choice C rationale:

Limiting each suction pass to no more than 10 seconds helps to prevent complications such as hypoxia and tissue damage.

Choice D rationale:

Providing oral or nasal care after suctioning helps maintain the patient's airway, promote comfort, and prevent infections.

Choice E rationale:

Applying continuous suction while withdrawing the catheter is not recommended as it can cause trauma to the airway and should be avoided during sterile suctioning.

Choice D rationale:

Before performing sterile suctioning on a patient with an endotracheal tube (ETT), the nurse should preoxygenate the patient with 100% oxygen. Suctioning can temporarily decrease oxygen levels in the airway, and preoxygenation helps prevent hypoxia during the procedure.

Choice A rationale:

Checking the patient's blood pressure is not directly related to the preparation for sterile suctioning. However, the nurse should monitor vital signs during and after the procedure.

Choice B rationale:

Placing the patient in the supine position is not a specific requirement for sterile suctioning. The nurse should position the patient appropriately for the procedure to ensure optimal access to the airway.

Choice C rationale:

Inserting the catheter without resistance is not a recommended action. The nurse should assess the patient's airway and ensure proper placement of the suctioning catheter to avoid causing injury or damage.

Choice A rationale:

The nurse should limit each suction pass to no more than 10 seconds to minimize the risk of tissue damage and hypoxia. Prolonged suctioning can cause trauma to the mucosa and lead to inadequate oxygenation.

Choice B rationale:

The nurse should apply suction while inserting the catheter to prevent the catheter from touching the airway walls before suction is initiated. This helps avoid stimulating the gag reflex and causing discomfort to the client.

Choice C rationale:

Rotating the catheter between the thumb and forefinger helps to facilitate even suctioning and prevent the catheter from adhering to the airway walls. It allows for effective removal of secretions without causing harm to the delicate tissues.

Choice D rationale:

After each suction pass, the nurse should rinse the catheter and tubing with saline to maintain its patency and prevent the buildup of secretions. This practice ensures that subsequent suctions are effective in clearing the airway.

Choice E rationale:

Suctioning more than three times in a row is not recommended because it can lead to hypoxia and tissue trauma. Frequent suctioning can reduce the oxygen levels in the airway and cause damage to the delicate tissues.

Choice C rationale:

The nurse should acknowledge the patient's anxiety and respond empathetically. Assuring the patient that the nurse will explain each step during the procedure can help alleviate anxiety. This approach promotes trust and helps the patient feel more in control, which is important for patient cooperation during the suctioning procedure.

Choice A rationale:

Telling the patient not to worry and that it won't take long may come across as dismissive and not address the patient's concerns adequately.

Choice B rationale:

Offering to postpone the procedure is an option, but the nurse should first attempt to address the patient's anxiety and provide reassurance. If the anxiety persists despite the explanation, postponing the procedure can be considered.

Choice D rationale:

Dismissing the patient's anxiety by stating that suctioning is routine may not effectively address the patient's feelings and may not be comforting.

Choice D rationale:

The nurse should respond by acknowledging the discomfort and pausing the procedure to reposition the nasopharyngeal tube. Repositioning can help alleviate the discomfort while ensuring the oxygenation needs are still met.

Choice A rationale:

Increasing the suction pressure may exacerbate the discomfort and cause further irritation to the nose and airway.

Choice B rationale:

Instructing the client to breathe through the mouth may not adequately address the discomfort and may not be feasible if the oxygenation is dependent on the nasopharyngeal tube.

Choice C rationale:

Although explaining the necessity of suctioning is important, it does not directly address the client's immediate discomfort. The priority is to address the client's comfort and safety during the procedure.

Choice A rationale:

The nurse should not discard the used catheter and gloves into a regular trash bin because they were used in a sterile procedure, and improper disposal could lead to the risk of contamination and infection for both the patient and others.

Choice B rationale:

Although it is important to assess the patient's response to suctioning, including vital signs, this should not be the immediate next step after completing sterile suctioning. First, the nurse should ensure their own and the patient's safety by following proper infection control measures.

Choice C rationale:

After completing sterile suctioning, the nurse should perform hand hygiene to prevent the spread of infection and then don a new pair of sterile gloves before performing any other tasks or assessments. This step ensures that the nurse maintains a sterile field and minimizes the risk of introducing pathogens into the patient's airway.

Choice D rationale:

Increasing the suction pressure for one last pass is not necessary and may cause harm to the patient's airway. Proper suctioning technique involves limiting the suctioning time and pressure to avoid tissue damage and potential complications.

Choice A rationale:

Cleaning the inner cannula once a week is insufficient to maintain proper hygiene for a patient with a tracheostomy tube. The inner cannula should be cleaned more frequently, as directed by the healthcare provider, to prevent the accumulation of secretions and potential respiratory complications.

Choice B rationale:

Deflating the cuff before cleaning the tracheostomy tube is not recommended because it may lead to aspiration of secretions or loss of the airway seal. The cuff should only be deflated when it is necessary to remove or change the tracheostomy tube.

Choice C rationale:

Using cotton-tipped applicators to clean the stoma is not the recommended method for tracheostomy care. Sterile tracheostomy care kits usually include specialized brushes or swabs designed for this purpose, ensuring effective and safe cleaning of the stoma without the risk of shedding fibers or causing injury.

Choice D rationale:

Changing the tracheostomy ties every 24 hours is the appropriate action. Regular changing of the ties helps prevent complications such as skin breakdown, ensures a secure fit of the tracheostomy tube, and reduces the risk of infection.

Choice A rationale:

Limiting the suctioning time to 15 seconds may still be too long for some patients, increasing the risk of hypoxia and other complications related to prolonged suctioning. The optimal suctioning time should be shorter to minimize adverse effects.

Choice B rationale:

Limiting the suctioning time to 20 seconds is longer than the recommended duration. Prolonged suctioning can cause hypoxia, increased intracranial pressure, and other adverse effects, making it crucial to keep the time as short as possible.

Choice C rationale:

Suctioning time should generally be limited to 10 seconds to reduce the risk of complications while effectively clearing the patient's airway. This duration allows for adequate removal of secretions without causing significant disturbances to the patient's oxygenation and hemodynamic stability.

Choice D rationale:

Limiting the suctioning time to 5 seconds is too short to effectively clear secretions from the airway, especially in patients with excessive or tenacious secretions. Sufficient time is needed to ensure proper removal of respiratory secretions and maintain the patient's airway patency.

Choice A rationale:

The nurse should not insert the catheter until resistance is met during nasopharyngeal suctioning. This action could cause trauma to the nasal mucosa or other structures in the nasopharynx.

Choice B rationale:

Preoxygenating the patient with 100% oxygen is important before nasopharyngeal suctioning to prevent hypoxia during the procedure. Suctioning can temporarily decrease oxygen levels, so preoxygenation helps maintain adequate oxygenation.

Choice C rationale:

Applying intermittent suction while inserting the catheter is not recommended during nasopharyngeal suctioning. Continuous suction is preferred for effective removal of secretions.

Choice D rationale:

Limiting each suction pass to no more than 15 seconds is an essential practice during nasopharyngeal suctioning. Prolonged suctioning can cause hypoxia and discomfort for the patient.

Choice E rationale:

Rinsing the catheter and tubing with saline after each suction pass helps maintain patency and prevent the accumulation of secretions, ensuring effective suctioning during the procedure.