A patient who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the most important consideration for the nurse when suctioning this patient?
A) Avoid applying suction on or near the graft site
B) Position the patient on his non-operative side with the head of the bed down
C) Assess viability of the graft before beginning suctioning
D) Evaluate the patient's ability to swallow saliva and clear fluids
Ans: A
Feedback: The nurse should avoid positioning the suction catheter on or near the graft suture lines. Application of suction in these areas could damage the graft. Following a modified radical neck dissection with graft, the patient is usually positioned with the head of the bed elevated to promote drainage and reduce edema. Assessing viability of the graft is important but is not part of the suctioning procedure and may delay the initiation of suctioning. Maintenance of a patent airway is a nursing priority. Similarly, the patient's ability to swallow is an important assessment for the nurse to make; however, it is not directly linked to the patient's need for suctioning.
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