The nurse is performing deep tracheal suctioning of a patient with a respiratory disorder. Which action demonstrates appropriate technique?
a. The nurse maintains clean technique.
b. The nurse places the patient in a side-lying position.
c. The nurse suctions the patient for 10 to 15 seconds.
d. The nurse reassures the patient that he will feel no discomfort.
C
The suctioning, which is done during extraction of the suction tip, should not last more than 10 to 15 seconds as it deprives the patient of oxygen. Deep tracheal suction requires sterile tech-nique, and the patient should be positioned with the neck slightly extended to facilitate entrance into the trachea. Even though the procedure does not last for a long time, suctioning is uncom-fortable for the patient.
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During an assessment, the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table,
the nurse should expect that a normal finding at this point would be: a. Significant elevational pallor. b. Venous filling within 15 seconds. c. No change in the coloration of the skin. d. Color returning to the feet within 20 seconds of assuming a sitting position.
Long-term oxygen therapy has been prescribed for a patient whose chronic obstructive pulmonary disease (COPD) has recently increased in severity. When teaching this patient about this treatment modality, what information should the nurse provide?
A) "In time, you will learn to effectively adjust your flow rates depending on the dyspnea you are experiencing or that you anticipate." B) "It's important to use your oxygen as ordered and not to base it solely on your shortness of breath at the time." C) "A good rule of thumb is to temporarily stop your oxygen whenever you feel like you could comfortably go without it." D) "Try to predict those situations where you'll need oxygen and apply your nasal prongs 30 minutes ahead of time."
A patient with type 1 diabetes asks why his 0700 insulin has been changed from NPH insulin to 70/30 premixed insulin. What is the best explanation by the nurse that explains about 70/30 insu-lin mixture?
a. It is absorbed more rapidly into the blood-stream. b. It has no peak action time and lasts all day. c. It makes insulin administration easier and safer. d. It provides a bolus of rapid-acting insulin to prevent hyperglycemia after breakfast.
A physician has ordered, "Clear liquids, advance as tolerated." A nurse identifies that which of the following factors indicate that the patient is not yet ready to advance his or her diet? Select all that apply
1. Hypoactive bowel sounds 2. Nausea 3. Complaints of indigestion 4. Hunger 5. Excessive thirst