The nurse listens to the lung sounds of a postoperative client and determines that the client is not able to clear the secretions from the lungs. What intervention should the nurse provide prior to suctioning?
A) Hyperoxygenate the client with 100% oxygen.
B) Place the client in the supine position.
C) Plan to suction for at least 20 seconds to remove secretions.
D) Administer a sedative prior to suctioning.
A
Feedback:
Hyperoxygenate with 100% oxygen before suctioning; do not suction for more than 10 to 15 seconds. Suctioning removes oxygen and can cause hypoxemia, myocardial ischemia, and dysrhythmias. Hyperoxygenation saturates the blood and hemoglobin to compensate for temporary removal during suctioning. Elevate the head of the bed, not place the client in the supine position. Administering a sedative may cause respiratory depression and should be avoided prior to suctioning so the cough reflex will not be depressed.
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