A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Rationale

A. Set the suction device to 120 mm Hg: Adult nasopharyngeal suctioning requires suction pressure between 100 and 150 mm Hg to effectively remove secretions without damaging mucosal tissue. Setting the device to 120 mm Hg falls safely within this range and provides adequate negative pressure for efficient suctioning.

B. Apply suction to the catheter during insertion: Suction should never be applied during catheter insertion because it increases the risk of mucosal injury and can cause hypoxia. The catheter must be inserted gently to the appropriate depth before suctioning is activated on withdrawal. This helps protect the airway structures and maintains patient safety during the procedure.

C. Have the client tuck his chin to his chest during suctioning: The chin-to-chest position narrows the airway passage and makes catheter insertion more difficult. Nasopharyngeal suctioning requires the "sniffing" position, where the head is slightly extended to align the airway for smoother catheter passage.

D. Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used because they can irritate mucous membranes and pose a risk if aspirated. Water-soluble lubricants are recommended since they reduce friction, minimize trauma, and dissolve easily if small amounts enter the airway.

Rationale

A. Place the client in a supine position: Placing a client supine is not necessary for restraint use and may increase the risk of aspiration, especially in a client with a PEG tube. Positioning should prioritize safety and comfort, typically semi-Fowler’s for feeding.

B. Remove the restraints every 2 hr: Restraints must be removed at least every 2 hours to assess skin integrity, circulation, range of motion, and the client’s need for continued restraint. Regular release prevents complications such as skin breakdown, nerve injury, or impaired circulation.

C. Secure the straps with a square knot: Restraint straps should be secured using a quick-release knot, not a square knot, to allow rapid removal in an emergency. Using an incorrect knot can delay urgent intervention and compromise safety.

D. Attach the straps to the side rails of the bed frame: Restraints should be attached to the bed frame not the side rails that move, or another fixed point, to prevent injury. Attaching to movable side rails can cause entrapment or worsen injury if the rails are raised or lowered.