The client develops respiratory distress during suctioning of the endotracheal (ET) tube. Which does the nurse implement for an initial response? (Select all that apply.)
1. Stop the suctioning.
2. Request assistance.
3. Administer oxygen.
4. Continue to suction.
5. Suction oropharynx.
6. Encourage coughing.
1, 3
1, 3, and 4. The nurse withdraws the catheter, stops suctioning to assess the client, and administers oxygen to relieve the respiratory distress. The nurse stabilizes the client and gathers assessment data for planning follow-up nursing care.
2. If the client's respiratory status does not improve quickly, the nurse calls for assis-tance and collaborates with the provider.
5 and 6. The nurse avoids suctioning the oropharynx until the respiratory distress im-proves unless it is indicated because it is an unusual cause of respiratory distress. If the client is alert and awake, the nurse can ask the client to cough if assessment data supports the intervention.
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