The nurse delegates suctioning to the nursing assistant and needs to direct the assistant's actions. Which does the nurse include in the nursing assistant's directions?

Question

1. Perform sterile dressing change for client's new tracheostomy.
2. Insert catheter into endotracheal tube until resistance is met.
3. Suction deeply into trachea for clients with respiratory distress.
4. Suction around client endotracheal tube with Yankauer catheter.

Answer 1

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4. The nurse instructs the nursing assistant to suction around the client's endotracheal tube with the Yankauer suction catheter to prevent oropharyngeal secretions from accumulating on top of the ET's cuff.
1 and 3. The nurse retains responsibility for the client's new tracheostomy dressing changes and for deep tracheal suctioning in acutely ill clients because these interven-tions require nursing judgment and critical thinking skills.
2. The nursing assistant receives training to perform the task of oral suctioning but does not suction the ET because it is a sterile procedure.