A nurse is caring for a preschooler.
Which of the following findings should the nurse report to the healthcare provider immediately? (Select all that apply)

Choice A rationale

Lubricating the suction catheter tip with sterile saline is not recommended because it can introduce bacteria into the tracheostomy tube and cause infection.

Choice B rationale

Hyperventilating the patient on 100% oxygen prior to suctioning is not necessary and can cause complications such as oxygen toxicity.

Choice C rationale

Performing chest physiotherapy prior to suctioning is not typically done during tracheostomy care. Chest physiotherapy is a separate procedure that involves physical techniques to remove mucus from the respiratory tract.

Choice D rationale

Suctioning two to three times with a 60-second pause between passes is the correct action. This helps to remove secretions effectively without causing hypoxia.

Choice A rationale

Positioning the head of the patient’s bed flat is not typically recommended after a laryngectomy. Instead, the head of the bed is often elevated to help reduce swelling and improve breathing.

Choice B rationale

Providing the patient with humidified air can help keep the airway moist and reduce discomfort, making it a common practice after a laryngectomy.

Choice C rationale

While keeping the surgical site clean is important, cleaning the patient’s sutures every 8 hours is not a standard recommendation and may vary based on the surgeon’s instructions.

Choice D rationale

Suctioning the patient’s mouth on the side of the surgery is not typically recommended as it could potentially disrupt the surgical site.