The nurse would determine that tracheal suctioning is needed if which of the following is noted?
1. Arterial oxygen level of 90 mm Hg
2. Congested breath sounds in the lung fields
3. Two hours elapsed since the last suctioning
4. Respiratory rate of 18 breaths/min, up from 16 breaths/min
2
Rationale: Suctioning is indicated only when the client has adventitious breath sounds or has accumulation of secretions. It is not performed routinely according to time elapsed since the last suctioning ("two hours elapsed since the last suctioning"). Arterial blood gas results and respiratory rate ("arterial oxygen level of 90 mm Hg" and "respiratory rate of 18 breaths/min, up from 16 breaths/min") are not good indicators of the need for suctioning because they may be influenced by a number of other factors in addition to the need for suctioning.
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