The client is lethargic and unable to clear oral secretions effectively. Which does the nurse use to suction oropharyngeal secretions from the client?
1. Delegate oral suctioning to the nursing assistant.
2. Loosen oral secretions with normal saline solution.
3. Suction the nose, mouth, and throat with catheter.
4. Use a clean catheter to suction the nose and mouth.
1
1. The nurse delegates oropharyngeal suctioning to the nursing assistant as necessary and retains responsibility for client assessment. The nurse also remains responsible for instructing and supervising the nursing assistant. The nurse instructs the nursing assistant to report changes in client's oxygen saturation or respiratory rate during and after suctioning.
2. The nurse avoids instilling saline solution into the client's oropharynx, to prevent aspiration.
3. Suctioning the nose and throat are not indicated.
4. The nurse uses a sterile catheter for nasopharyngeal suctioning to prevent conta-mination of the nasal passages or trachea.
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