NUR-227 Med-Surg Clinical Skills
Questions and Correct Answers
Which action is part of the preparation for nasotracheal suctioning?
A. Place the patient in a supine position.
B. Preoxygenate the patient with 100% oxygen.
C. Suction 100 mL of warm tap water to flush the suction catheter.
D. Place water-soluble lubricant onto the open sterile catheter package. ✅D. Place
water-soluble lubricant onto the open sterile catheter package.
Rationale: Lubricant facilitates the insertion of the catheter. The patient should be in the
semi-Fowler's position or sitting upright. Preoxygenation is not needed before
nasotracheal suctioning. Sterile water or sterile 0.9% sodium chloride is used to flush
the catheter.
Which response would the nurse report immediately if it occurred in association with
nasotracheal suctioning?
A. Patient complains of discomfort during the procedure.
B. Patient has a severe bout of nonproductive coughing and complains of sore throat.
C. After oxygen delivery device has been reapplied on completion of the procedure,
patient's pulse oximetry reading falls to 88%.
D. Patient's pulse rate increases by 10 bpm. ✅C. After oxygen delivery device has
been reapplied on completion of the procedure, patient's pulse oximetry reading falls to
88%.
Rationale: This decline in peripheral blood oxygen saturation must be reported. It
represents a decline in the patient's condition following a procedure that should have
improved his or her SpO2 reading. Discomfort need not be reported. Symptoms of
coughing and sore throat do not require immediate reporting. This change in heart rate
is anticipated with the procedure. Taken by itself, it does not require reporting.
While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has
fallen from 102 bpm to 80 bpm. What is the best course of action?
A. Encourage the patient to take several deep breaths.
B. Interrupt suction to the catheter for at least 10 seconds.
C. Discontinue suctioning by removing the suction catheter.
D. Assess the patient's pulse oximetry reading to see if oxygenation is adequate. ✅C.
Discontinue suctioning by removing the suction catheter.
Rationale: A drop in pulse of 20 bpm or more necessitates discontinuation of suctioning
and removal of the catheter. Deep breathing will not adequately address the patient's
response. Pausing the suctioning briefly will not adequately address the patient's
response. Taking an oximetry reading will not address the patient's response.
, As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and
says, "I feel like I'm going to throw up." What is the nurse's best response?
A. Complete the catheter insertion in 5 seconds or less.
B. Remove the catheter.
C. Encourage the patient to take several deep breaths to minimize the nausea.
D. Stop advancing the catheter, and allow the patient to rest for several minutes. ✅B.
Remove the catheter.
Rationale: Gagging and nausea indicate that the catheter has probably entered the
esophagus and must be removed. Attempting to complete the insertion could increase
the gagging and nausea. Deep breathing is not the appropriate response to nausea
when it occurs during insertion of a nasotracheal catheter. The catheter is probably in
the esophagus and must be removed. Advancing the catheter after a period of rest will
simply lead to more gagging and nausea.
How does the nurse evaluate the effect of nasotracheal suctioning on a patient's
respiratory status?
A. Asking the patient about symptoms of respiratory difficulty.
B. Comparing respiratory assessment data from before and after the suctioning
procedure.
C. Confirming that the patient's pulse oximetry value is >90%.
D. Auscultating the patient's chest after suctioning. ✅B. Comparing respiratory
assessment data from before and after the suctioning procedure.
Rationale: Comparing presuctioning and postsuctioning assessment data will provide
the best measure of the procedure's efficacy. The patient may have needed suctioning
without experiencing respiratory difficulty. The patient's normal pulse oximetry value
may not be >90%. The nurse might be able to auscultate clear breath sounds; however,
this information must be evaluated in light of presuctioning and postsuctioning
assessment data to evaluate the procedure's efficacy.
Which action would the nurse perform when preparing to suction a patient's
oropharynx?
A. Apply sterile gloves.
B. Place the patient in a semi-Fowler's or sitting position.
C. Remove the nasal cannula.
D. Flush the suction catheter with 200 mL of warm tap water. ✅B. Place the patient in
a semi-Fowler's or sitting position.
Rationale: A semi-Fowler's or sitting position would facilitate this intervention. This
intervention would be performed using clean, not sterile, technique. The nasal cannula
can remain in place to deliver oxygen during the intervention. Sterile water or sterile
normal saline is preferred to tap water, and a quantity of only 100 mL is needed.
After oropharyngeal suctioning, what does the nurse do with the supplies?
Questions and Correct Answers
Which action is part of the preparation for nasotracheal suctioning?
A. Place the patient in a supine position.
B. Preoxygenate the patient with 100% oxygen.
C. Suction 100 mL of warm tap water to flush the suction catheter.
D. Place water-soluble lubricant onto the open sterile catheter package. ✅D. Place
water-soluble lubricant onto the open sterile catheter package.
Rationale: Lubricant facilitates the insertion of the catheter. The patient should be in the
semi-Fowler's position or sitting upright. Preoxygenation is not needed before
nasotracheal suctioning. Sterile water or sterile 0.9% sodium chloride is used to flush
the catheter.
Which response would the nurse report immediately if it occurred in association with
nasotracheal suctioning?
A. Patient complains of discomfort during the procedure.
B. Patient has a severe bout of nonproductive coughing and complains of sore throat.
C. After oxygen delivery device has been reapplied on completion of the procedure,
patient's pulse oximetry reading falls to 88%.
D. Patient's pulse rate increases by 10 bpm. ✅C. After oxygen delivery device has
been reapplied on completion of the procedure, patient's pulse oximetry reading falls to
88%.
Rationale: This decline in peripheral blood oxygen saturation must be reported. It
represents a decline in the patient's condition following a procedure that should have
improved his or her SpO2 reading. Discomfort need not be reported. Symptoms of
coughing and sore throat do not require immediate reporting. This change in heart rate
is anticipated with the procedure. Taken by itself, it does not require reporting.
While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has
fallen from 102 bpm to 80 bpm. What is the best course of action?
A. Encourage the patient to take several deep breaths.
B. Interrupt suction to the catheter for at least 10 seconds.
C. Discontinue suctioning by removing the suction catheter.
D. Assess the patient's pulse oximetry reading to see if oxygenation is adequate. ✅C.
Discontinue suctioning by removing the suction catheter.
Rationale: A drop in pulse of 20 bpm or more necessitates discontinuation of suctioning
and removal of the catheter. Deep breathing will not adequately address the patient's
response. Pausing the suctioning briefly will not adequately address the patient's
response. Taking an oximetry reading will not address the patient's response.
, As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and
says, "I feel like I'm going to throw up." What is the nurse's best response?
A. Complete the catheter insertion in 5 seconds or less.
B. Remove the catheter.
C. Encourage the patient to take several deep breaths to minimize the nausea.
D. Stop advancing the catheter, and allow the patient to rest for several minutes. ✅B.
Remove the catheter.
Rationale: Gagging and nausea indicate that the catheter has probably entered the
esophagus and must be removed. Attempting to complete the insertion could increase
the gagging and nausea. Deep breathing is not the appropriate response to nausea
when it occurs during insertion of a nasotracheal catheter. The catheter is probably in
the esophagus and must be removed. Advancing the catheter after a period of rest will
simply lead to more gagging and nausea.
How does the nurse evaluate the effect of nasotracheal suctioning on a patient's
respiratory status?
A. Asking the patient about symptoms of respiratory difficulty.
B. Comparing respiratory assessment data from before and after the suctioning
procedure.
C. Confirming that the patient's pulse oximetry value is >90%.
D. Auscultating the patient's chest after suctioning. ✅B. Comparing respiratory
assessment data from before and after the suctioning procedure.
Rationale: Comparing presuctioning and postsuctioning assessment data will provide
the best measure of the procedure's efficacy. The patient may have needed suctioning
without experiencing respiratory difficulty. The patient's normal pulse oximetry value
may not be >90%. The nurse might be able to auscultate clear breath sounds; however,
this information must be evaluated in light of presuctioning and postsuctioning
assessment data to evaluate the procedure's efficacy.
Which action would the nurse perform when preparing to suction a patient's
oropharynx?
A. Apply sterile gloves.
B. Place the patient in a semi-Fowler's or sitting position.
C. Remove the nasal cannula.
D. Flush the suction catheter with 200 mL of warm tap water. ✅B. Place the patient in
a semi-Fowler's or sitting position.
Rationale: A semi-Fowler's or sitting position would facilitate this intervention. This
intervention would be performed using clean, not sterile, technique. The nasal cannula
can remain in place to deliver oxygen during the intervention. Sterile water or sterile
normal saline is preferred to tap water, and a quantity of only 100 mL is needed.
After oropharyngeal suctioning, what does the nurse do with the supplies?
