The nurse is preparing to suction a client's tracheostomy.
Place the following actions in the order in which they should be performed, starting from first to last.
The nurse is preparing to suction a client's tracheostomy.
Place the following actions in the order in which they should be performed, starting from first to last.
Incorrect
Identify the client, perform hand hygiene, and gather supplies.
Apply a continuous pulse oximeter to the client.
Perform hand hygiene and apply personal protective equipment (PPE).
Using an aseptic technique, open the suction kit or catheter package and prepare supplies.
Apply sterile gloves.
Suction the client as the catheter is removed for a maximum of 15 seconds.
Place the tip of catheter into a sterile basin and suction a small amount of normal saline solution from the basin by occluding the suction vent.
Correct Answer is:
Identify the client, perform hand hygiene, and gather supplies.
Apply a continuous pulse oximeter to the client.
Perform hand hygiene and apply personal protective equipment (PPE).
Using an aseptic technique, open the suction kit or catheter package and prepare supplies.
Apply sterile gloves.
Place the tip of catheter into a sterile basin and suction a small amount of normal saline solution from the basin by occluding the suction vent.
Suction the client as the catheter is removed for a maximum of 15 seconds.
Statistics
Difficulty level - Hard
36%of peers got it right
Time taken - 109 s
Subject/Lesson
Subject
Adult Health
Lesson
Respiratory
Client Need
Test Plan
Reduction of Risk Potential
Related Topic
Potential for Complications of Diagnostic Tests/Treatments/Procedures
Item Type
Item Type
Application
Explanation
Correct sequence:
- The nurse should first identify the client, perform hand hygiene, and gather supplies. The nurse will perform hand hygiene upon entering the client's room; this is standard. Once the client has been identified, the nurse will gather the supplies needed, including a tracheostomy suctioning kit, personal protective equipment, pulse oximeter device, working suction, bag-valve mask, and supplemental oxygen. The nurse should position the client semi-Fowlers or high-Fowlers.
- The nurse should place a continuous pulse oximeter device on the client because, during the procedure, hypoxia would cause the nurse to abandon the procedure and administer supplemental oxygen. If the pulse ox is 92% or less, the procedure should be stopped, and supplemental oxygen should be provided. The nurse should turn on the wall suction to continuous and set it between 80 and 150 mm Hg.
- Hand hygiene should be performed, and PPE should be applied. The nurse will need to perform hand hygiene again because they made contact with the supplies and the client. The PPE necessary for this procedure includes (a mask with a face shield or goggles and a gown if necessary). The nurse will execute this step because hands should be washed before the application of PPE. The nurse does not put on PPE upon entry because the nurse needs to verify the client and gather supplies. These tasks do not require PPE.
- Open the tracheostomy kit using an aseptic approach. The bedside table should be cleaned prior with a disinfectant wipe, and the table should be at the nurses' waist to prevent contamination. The nurse will remove the sterile gloves.
- Apply sterile gloves. Apply sterile gloves to each hand or nonsterile glove to the nondominant hand and sterile glove to the dominant hand.
- Place the tip of the catheter into a sterile basin and suction a small amount of normal saline solution from the basin by occluding the suction vent. This lubricates the catheter and tests its patency. The client should be preoxygenated prior to each suction pass. Instruct the client that suction will begin as the catheter will be removed and coughing is normal.
- Suction the client as the catheter is removed for a maximum of 15 seconds. The suctioning should be performed as the catheter is removed in a twirling motion. 10 to 15 seconds is the duration for each suctioning pass. The nurse should assess the client's pulse oximetry during the procedure and abort if it is 92% or less.
- Following the suctioning, the nurse may then proceed to perform tracheostomy care.
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