Clinical Key

After suctioning the oropharyngeal airway with a rigid suction device, which action should be performed?

Place the device in a container that is not airtight.

The nurse is teaching family members how to use the bulb suction on their infant. What is the correct method?

The bulb syringe should be compressed before it is inserted.

Which finding is an expected outcome of suctioning the patient's oropharynx?

Absence of gurgling in the oropharyngeal area

Which condition is an expected outcome of effective oropharyngeal suctioning?

Absence of vomitus in the mouth

A nurse is teaching a new graduate nurse about tracheostomy tubes. Which statement by the new graduate nurse indicates understanding of the capabilities of a fenestrated tracheostomy tube?

"A fenestrated tube allows the patient to speak."

Which statement by the family member of a patient with a tracheostomy tube indicates the need for more education?

"He will need to be on the ventilator as long as he has the trach."

Which instruction should be included when educating the family about signs of severe respiratory distress while performing oropharyngeal suctioning in the home?

"Pick up the phone and call 911."

Which is the best response by the nurse to the family, while preparing to suction the patient with the family present?

"Suctioning may be uncomfortable, causing temporary shortness of breath or coughing."

What instruction should be given to a conscious patient before starting oropharyngeal suctioning?

"Try to cough before I begin."

The nursed performed nasopharyngeal suctioning on an older adult patient. Which outcome should the nurse expect to find when assessing the patient?

A return of clear, audible breath sounds

A nurse is performing tracheal suctioning. Which action is essential to prevent hypoxemia during suctioning?

Administer 100% oxygen before suctioning.

A patient with a tracheostomy tube is receiving mechanical ventilation. The nurse observes a decrease in the patient's oxygen saturation, an increase in peak airway pressure, and frequent coughing episodes. What is the most appropriate nursing action?

Administer 100% oxygen to the patient for 30 to 60 seconds by increasing the FIO2 on the ventilator and provide closed-system suctioning until the tube is clear (but less than 15 seconds).

While receiving tracheostomy care, the patient's oxygen saturation drops to 87%. What action should be the nurse's next intervention?

Administering 100% oxygen to the patient -- hyperoxygenate the patient

To allow adequate ventilation and oxygenation during nasopharyngeal suctioning, which action should the nurse take?

Allow adequate time between suctioning passes.

Suctioning may result in which serious complications?

Arrhythmias and increased ICP

How many passes should be performed during a nasotracheal suctioning procedure?

As few as possible

Which action should the nurse include when providing tracheostomy care?

Cleaning the inner cannula with 0.9% sodium chloride solution

Which statement best describes a benefit of closed-suction technique?

Closed-suction technique allows for a continued tidal volume delivery to the patient with minimal loss of lung volume.

The nurse suctions the tracheostomy tube of a patient who received a tracheostomy the night before. When suctioning, the nurse notices a moderate amount of bloody secretions. The patient notices the blood and appears to be disturbed by it. What should the nurse do next?

Comfort the patient and explain that blood in the sputum is normal after tracheostomy tube insertion.

While assessing a patient who is receiving mechanical ventilation through an ET tube, the nurse observes an increase in peak airway pressure and thick beige secretions. What is the most appropriate nursing action?

Consider administering 100% oxygen to the patient and then suction secretions from the patient's airway using the closed-system technique.

During suctioning of secretions from a patient who is intubated, the patient develops cardiac arrhythmias, with an acute drop in oxygen saturation. What is the priority in this situation?

Discontinue suction and administer 100% oxygen to the patient using the ventilator.

While reviewing a patient's medication list before performing oropharyngeal suctioning, which medication raises concern as a risk for this procedure?

Enoxaparin

Which is the maximum number of passes per suctioning procedure?

Four

The nurse is preparing to perform nasopharyngeal suctioning. In which position should the nurse place the patient?

Fowler with the head hyperextended

Which risk associated with nasotracheal suctioning should the nurse monitor the patient for?

Hypoxemia

When performing nasotracheal suctioning, which outcome should the nurse expect?

Improved breath sounds and decreased adventitious sounds

The nurse is preparing to perform nasotracheal suctioning. Unless contraindicated, what should the nurse do first before suctioning?

Increase supplemental oxygen per the practitioner's order.

When performing nasotracheal suctioning for an adult patient, which action should the nurse take?

Insert the catheter until resistance is felt in the airway or the patient begins coughing.

The nurse is preparing the suction catheter. What is the appropriate method to decrease trauma to the patient's nose?

Lightly coat the distal tip of the catheter with a water-soluble lubricant.

For a patient who requires nasopharyngeal suctioning, how often should the nurse suction?

Only if there are signs and symptoms of airway compromise

When securing the tracheostomy ties, the nurse should tie the ends in a double square knot, allowing for which outcome?

One loose or two snug finger widths of slack

Which monitoring parameter is most important to use when assessing for effectiveness of oropharyngeal suctioning?

Oxygen saturation

When preparing a patient for nasopharyngeal suctioning, which steps should the nurse perform?

Place a pulse oximeter on the patient's finger and obtain a reading before and throughout the suctioning procedure.

When performing nasopharyngeal suctioning for an adult patient, which step should the nurse perform?

Perform an anatomic assessment to determine the appropriate catheter insertion depth.

After completing nasopharyngeal suctioning, which of these actions should the nurse perform first?

Pull the gloves off over the rolled catheter and discard.

The nurse has just completed a single suction pass for a patient with an artificial airway. What is the next priority?

Reassess the patient to determine the effectiveness of the intervention.

If an obstruction is met when the catheter is inserted, which step should the nurse perform?

Remove the catheter and try the other naris.

Which action should be taken before performing oropharyngeal suctioning?

Remove the oxygen mask and keep it near the patient's face.

A patient who is comatose but not intubated, requires frequent oral suctioning. After suctioning, in which position should the patient be placed?

Sims position

An older adult patient with diabetes mellitus needs tracheostomy care. This patient is at high risk for which complication?

Skin breakdown at the stoma

The nurse is caring for a patient receiving mechanical ventilation. During open suctioning, the nurse observes a decrease in oxygen saturation from 95% to 85%. Before further suctioning attempts, what is the first action to take?

Stop suctioning and administer 100% oxygen to the patient for 30 to 60 seconds.

While performing the initial assessment, gurgling is heard coming from the patient's throat and copious amounts of saliva is observed in the patient's mouth. Which action is the most appropriate?

Suction the patient's mouth using a rigid suction device.

The nurse is passing a suction catheter for nasotracheal suctioning. What instructions should the nurse give the patient?

Tell the patient to take a deep breath.

The nurse is providing education to the family of an infant before discharge. Which education point should the nurse stress?

The infant may need frequent suctioning.

When cleaning a non-disposable inner cannula of a tracheostomy tube, which step should be included?

Use a small brush to remove secretions from the cannula

When suctioning a tracheostomy tube, what should the nurse do?

Use the dominant hand to maneuver the sterile suction catheter.

What is a possible complication of prolonged suctioning?

Vagal stimulation

In which situation should the nurse use a bulb syringe for nasotracheal suctioning?

When suctioning an infant

The nurse is performing nasotracheal suctioning on an older adult patient. When is it not appropriate to apply suction pressure?

When the catheter is introduced into the trachea

Which action is the most effective in helping health care team members communicate with a patient who has a cuffed, nonfenestrated tracheostomy tube?

*Provide pen and paper