The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is tolerating the procedure if which observation is made?
A. The skin color becomes cyanotic.
B. Secretions are becoming bloody.
C. Coughing occurs with suctioning.
D. Heart rate decreases from 78 to 54 beats/minute.
Answer: C. Coughing occurs with suctioning.
The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, and sudden development of bloody secretions. If any of these signs is observed, the nurse immediately stops suctioning and reports the adverse effect to the health care provider. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that he or she cannot tolerate the procedure.
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