The nurse needs to suction the client's oropharynx. Which should the nurse implement first?
1. Apply gloves and facemask.
2. Encourage the client to cough.
3. Reassess the respiratory status.
4. Remove supplemental oxygen.
1
1. The first nursing intervention for oropharyngeal suctioning is to apply a mask and gloves for self-protection against droplet contamination from client secretions.
2. The nurse encourages the client to cough during and after suctioning to mobilize secretions for expectoration because removing the secretions helps to maintain airway patency.
3. The nurse reassesses the client's respiratory status after oropharyngeal suctioning and compares the client data with the baseline assessment.
4. The nurse avoids removing the client's oxygen source if possible during suctioning to maintain client oxygenation and prepares the client for suctioning with hyperoxy-genation; however, if the nurse must remove the oxygen, it is removed immediately before suctioning.
4. The nurse connects the tubing and catheter after applying the mask and gloves.
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