The nurse is caring for a patient with an endotracheal tube. The nurse understands that endotracheal suctioning is needed to facilitate removal of secretions and that the procedure:
a. decreases intracranial pressure.
b. depresses the cough reflex.
c. is done as indicated by patient assessment.
d. is more effective if preceded by saline instillation to loosen secretions.
C
Suctioning is performed as indicated by patient's assessment. Suctioning is associated with increases in intracranial pressure; therefore, it is important to hyperoxygenate the patient prior to suctioning to reduce this complication. Suctioning can stimulate the cough reflex rather than depress this reflex. Saline instillation is associated with negative physiological outcomes and is not recommended as part of the suctioning procedure; it does not loosen secretions, which is a common misperception.
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