A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

Use medical asepsis when performing the procedure.

Apply suction for 10 seconds.

Advance the catheter 2 cm (0.8 in) after resistance is met.

Withdraw the catheter if the client begins coughing.

Answer and Explanation

The Correct Answer is B

A. Surgical asepsis (sterile technique) should be used for suctioning to prevent infection, not medical asepsis.

B. Applying suction for no longer than 10 seconds is appropriate to prevent hypoxia and trauma to the airway.

C. Advancing the catheter 2 cm after resistance is met is not advised; the catheter should not be forced beyond resistance to avoid injury.

D. The catheter should not be withdrawn if the client begins coughing; instead, it indicates the need for suctioning. If coughing occurs, the nurse should ensure the patient can breathe and may need to suction carefully.

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Correct Answer is A

Explanation

A. Making a referral for social services is appropriate as they can assist the client with discharge planning, home care services, and resources for palliative care to support the client's wishes.

B. While it is important to explain the risks of leaving against medical advice, the priority is to support the client’s desire to go home, rather than focusing on the potential consequences at this moment.

C. Contacting the facility chaplain could be beneficial for emotional support, but it does not address the immediate need for facilitating the client’s wish to go home.

D. Encouraging the client to continue with inpatient care contradicts their expressed desire to be with family, which is a crucial aspect of their emotional well-being in this situation.

A. "I am concerned about my child's future participation in team sports." B. "My child doesn't like to sit still for nebulizer treatments." C. "My child has only a small amount of mucus after percussion therapy." D. "I think that my child has been running a fever over the last couple of days."

Correct Answer is C

Explanation

A. Concerns about participation in team sports are important, but they do not directly warrant a request for a high-frequency chest compression vest.

B. Discomfort with nebulizer treatments suggests the need for alternate therapies but does not specifically indicate a need for the vest.

C. A statement regarding a small amount of mucus after percussion therapy suggests that traditional methods of airway clearance may not be effective enough, indicating a need for a high-frequency chest compression vest to help mobilize mucus.

D. A fever may indicate an infection or exacerbation but does not directly relate to the need for a high-frequency chest compression vest.

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A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

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