The patient has had throat surgery and has a tracheal tube in place. The nurse assesses that suctioning is necessary when the patient:
1. becomes restless and has increases in vital signs.
2. has decreased peak airway pressure.
3. shows diaphoresis.
4. is coughing frothy mucus.
1
The patient signals the need for suctioning by increased restlessness and an increase in vital signs. Peak airway pressures increase when suctioning is necessary. Frothy mucus is an ex-pectation.
PTS: 1 DIF: Cognitive Level: Analysis REF: 1214-1215
OBJ: 3 TOP: Suctioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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