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Exam 3 Adaptive Quizzing.
A health care provider prescribes oropharyngeal suctioning as needed A nurse is caring for a client who is re.ceiving mechanical ventilation
for a client in a coma. Which assessment made by the nurse indicates via an endotracheal tube with a high-volume, low-pressure cuff.
What
the need for suctioning?
Gurgling sounds with each breath
Fine crackles at the base of the lungs
Cyanosis in the nail beds of the
fingers
Dry cough at increasingly frequent intervals
problem is prevented when the nurse uses a high-volume, low-
pressure cuff?
Air leakage
Lung infection
Mucosal necrosis
Secretions in the upper airway produce gurgling sounds that interfere Tracheal secretion
with the free flow of air with each breath. Oropharyngeal suction will Mucosal necrosis is prevented because these cuffs do not compress
not address fine crackles at the base of the lungs. Cyanosis can
result from a variety of problems unrelated to the presence of
secretions; suctioning should be done only when secretions are
blocking the airway. Suctioning is not needed in the absence of
accumulated oropharyngeal secretions.
A client with a pulmonary embolus is intubated, and mechanical
ventilation is instituted. What should the nurse do when suctioning
the endotracheal tube?
Apply suction while inserting the catheter.
Hyperoxygenate with 100%
oxygen before and after
suctioning.
Use short, jabbing movements of the catheter to loosen secretions.
the capillary beds. A minimal air leak is desirable to ensure the lowest
possible pressure in the cuff while placement of the tube is
maintained. Surgical asepsis, not use of these cuffs, prevents
infection. Secretions will be increased because the cuff is a foreign
body in the trachea.
A postoperative client is being weaned from mechanical ventilation.
What is the most important factor for the nurse to consider when
organizing activities?
Remain with the client to assess
responses.
Allow family members to participate in the process.
Permit the client more extended times alone for independence.
Suction two to three times in quick succession to remove most of the Observe monitoring devices at the control panel of the ventilator.
secretions.
Suctioning also removes oxygen, which can cause cardiac
This is a critical time; the client's response to reduction of ventilator
support must be observed closely and evaluated for signs of
dysrhythmias; the nurse attempts to prevent this by hyperoxygenatingrespiratory distress (e.g., shallow breathing, restlessness, use of
the client before and after suctioning. To prevent trauma to the
trachea and hypoxia, suction should be applied only during catheter
removal. Using short, jabbing movements of the catheter may cause
tracheal damage and therefore is contraindicated. Suctioning should
