While performing nasotracheal suctioning, the nurse notes the older adult client is moving the head around and pulling at the nurse's hand to remove the suction catheter. Which actions by the nurse are appropriate?

Question

Select all that apply.
A) Remove the suction catheter
B) Lower the head of the bed
C) Hyperinflate the client's lungs
D) Apply restraints to the client's arms and legs
E) Hyperoxygenate the client

Answer 1

Answer: A, C, E

The older adult client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, hyperinflate the client's lungs, and hyperoxygenate the client. The client does not need to have restraints applied to all 4 extremities. The client should be in the Fowler or high-Fowler position.