A nurse is caring for an unconscious client who has undergone a tracheostomy. What measure should the nurse take while suctioning this client?
A) Place the client in a semi- or high Fowler's position.
B) Insert the suction catheter about an inch into the trachea.
C) Avoid applying suction when inserting the suction catheter.
D) Suction the tube continuously for at least 30 seconds.
C
Feedback:
The nurse should avoid applying suction when inserting the catheter; doing so may damage mucosa in the trachea and promote hypoxia. The nurse should place the unconscious client on his or her side, facing the nurse, not in a semi- or high Fowler's position, to prevent airway obstruction. The catheter should be inserted 4 to 5 inches into the trachea, not only about an inch, for proper positioning. Suctioning should not continue for longer than 10-second intervals in order to prevent the development of hypoxia.
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