Which nursing intervention in the preparation for or implementation of tracheal suctioning prevents tissue damage?
A. Monitoring oxygen saturation while suctioning
B. Applying suction only as the catheter is removed
C. Hyperoxygenating the client before starting the procedure
D. Selecting the largest catheter that fits into the tracheal lumen
B
The actual suction can pull tissue into the openings of the suction catheter and damage this deli-cate mucous membrane. Applying suction only during removal of the catheter (and using a twirling motion) increases the chances that secretions are actually present when suction is applied and reduces the time that the tissues are exposed to suction.
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What would be most appropriate to include in the plan of care for a child who has undergone surgery for removal of an astrocytoma?
A) Elevating the foot of the bed B) Positioning the child on his unaffected side C) Raising the head of the bed at least 45 degrees D) Administering large volumes of intravenous fluids
The nurse is caring for a postpartal client who is experiencing afterpains following the birth of her third child. Which of the following comfort measures should the nurse implement to decrease the client's pain? (Select all that apply.)
A. Offer warm blankets for her abdomen. B. Call the physician to report this finding. C. Inform her that this is not normal, and she will need an oxytocic agent. D. Massage the fundus of the uterus gently and observe lochia for clots. E. Administer a non-steroidal anti-inflammatory drug (NSAID).
An awake, alert 4-year-old child has just arrived at the emergency department after an ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in the following manner:
a. give half of the solution, and then repeat the other half in 1 hour. b. mix with a flavorful beverage in an opaque container with a straw. c. serve in a clear plastic cup so the child can see how much has been drunk. d. administer through a nasogastric tube, since the child will not drink it because of the taste.
An 81-year-old client has developed a fecal impaction while convalescing at home after hip surgery. Which of the following corrective actions should the nurse undertake?
A) Manually remove the feces with a gloved finger. B) Assist the client to sit on the commode to facilitate stool passage. C) Break up the impaction with external abdominal massage. D) Insert a flatus bag to prevent entrance of air into the rectum