While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often?
A) Every 2 hours when the patient is awake
B) When adventitious breath sounds are auscultated
C) When there is a need to prevent the patient from coughing
D) When the nurse needs to stimulate the cough reflex
Ans: B
Feedback:
It is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa.
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