A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching?

A) Reduced respiratory rate:
Acute pain typically triggers an increased respiratory rate rather than a reduced one. Pain activates the sympathetic nervous system, leading to increased respiratory effort as the body prepares to fight or flee.

B) Elevated blood pressure:
Elevated blood pressure is a common physiological response to acute pain. Pain activates the sympathetic nervous system, leading to the release of stress hormones like adrenaline, which constrict blood vessels and increase heart rate and blood pressure.

C) Constricted pupils:
Pain often causes pupil dilation rather than constriction. The body's fight-or-flight response to pain involves pupil dilation to enhance visual acuity and peripheral vision, allowing individuals to detect potential threats in their environment.

D) Decreased heart rate:
Acute pain typically results in an increased heart rate rather than a decreased one. Pain triggers the release of adrenaline, which increases heart rate as part of the body's stress response to prepare for action.

A) Allow the client to rest for 10 to 15 seconds after each suctioning attempt: Allowing the client to rest between suctioning attempts helps to minimize hypoxemia and reduces the risk of trauma to the airway mucosa. It also allows the client to recover from the physiological stress of suctioning before initiating another attempt.

C) Apply suction for less than 10 seconds: Prolonged suctioning can lead to hypoxemia and tissue trauma. The nurse should limit suctioning to less than 10 seconds per pass to minimize these risks and prevent complications such as mucosal damage and bleeding.

B) Set the suction pressure to 110 mm Hg: The appropriate suction pressure for endotracheal suctioning depends on various factors, including the client's age, condition, and clinical status. While suction pressures of 80 to 120 mm Hg are commonly used for adults, the specific pressure setting should be individualized based on the client's needs and should not exceed the safe range to prevent mucosal injury or hypoxemia.

D) Apply suction when inserting the catheter: Suction should be applied only during withdrawal of the catheter to minimize the risk of mucosal trauma and hypoxemia. Applying suction during catheter insertion can increase the risk of airway trauma and should be avoided.