Soru

Zorluk: OrtaReduction of Risk Potential

A nurse is preparing to perform open-system suctioning for a client with a tracheostomy tube. To reduce the risk of hypoxia and mucosal trauma, in which order should the nurse perform the following actions? Arrange the steps in the correct sequence from first to last.

  1. 1Preoxygenate the client with 100% oxygen.
  2. 2Insert the suction catheter without applying suction until resistance is met.
  3. 3Withdraw the catheter approximately 1 to 2 centimeters.
  4. 4Apply intermittent suction while rotating the catheter outward.
  5. 5Reassess the client's respiratory status and oxygen saturation.

Cevap

The correct sequence is to preoxygenate, insert without suction, withdraw slightly, apply suction while rotating outward, and finally reassess.
To reduce the risk of life-threatening complications such as hypoxemia, cardiac dysrhythmias, and mucosal trauma, the nurse must adhere to a strict procedural sequence. Preoxygenation provides a critical oxygen reserve. Inserting the catheter without suction protects the airway lining. Withdrawing the catheter slightly before applying suction prevents adherence to the carina, avoiding vagal stimulation. Applying suction only during withdrawal with a rotating motion safely removes secretions. Reassessing the client verifies the procedure's success and the client's stability.

Adım Adım Çözüm

1
Preoxygenate the client.
Increases the client's arterial oxygenation levels.
Prevents hypoxemia during the procedure.
2
Insert the catheter without applying suction.
The catheter reaches the level of the carina or mainstem bronchi.
Applying suction during insertion causes severe tissue trauma and oxygen depletion.
3
Withdraw the catheter 1 to 2 centimeters.
The catheter tip is moved away from the sensitive carina.
Prevents direct vagal stimulation and localized tissue damage when suction is applied.
4
Apply intermittent suction while rotating and withdrawing.
Secretions are safely cleared from the airway.
Rotation prevents the catheter tip from continuously adhering to one area of the tracheal mucosa.
5
Reassess the client.
Post-procedure baseline is established.
Ensures the airway is patent and the client has not suffered adverse effects.

Anahtar Kavram

Safe tracheostomy suctioning sequence to minimize hypoxia and mucosal trauma.
Tahmini Süre:1m 0s
Bu soruyu puanla