Question

a nurse is performing suctioning for a client who has a tracheostomy. which of the following actions should the nurse take? pull suction catheter back 1 cm (0.5 in) if the client starts coughing. allow 30 seconds between suctioning passes. hyperventilate the client with 50% oxygen for 30 seconds. perform a maximum of 4 passes with the suction catheter.

Explanation:

When suctioning a client with a tracheostomy, if the client starts coughing, pulling the suction catheter back 1 - 2 cm helps prevent tissue damage. The recommended interval between suctioning passes is 1 - 2 minutes, not 30 seconds. Pre - suctioning hyperventilation should be with 100% oxygen for 30 - 60 seconds, not 50% oxygen. A maximum of 3 suction passes is usually recommended.

Answer:

Pull suction catheter back 1 cm (0.5 in) if the client starts coughing.