Question

A nurse is trying to determine whether or not a patient's artificial airway should be suctioned. Which of the following fails to be an indication for suctioning?

A) Pulse oximetry 89%.
B) Pulmonary secretions.
C) 2 hours have elapsed since patient was last suctioned.
D) Patient has audible gurgling and appears restless.

Answer 1

The indication for suctioning that fails is the concept of performing suctioning after a set amount of time has elapsed (such as every 2 hours) without assessment of patient need. Indications for suctioning include low pulse oximetry, pulmonary secretions, and signs of physical distress, like audible gurgling and restlessness.(option c)

Step-by-step explanation:

A nurse determining whether a patient with an artificial airway should be suctioned will evaluate various clinical signs and patient needs. The indications for suctioning an artificial airway include:

• A drop in oxygen saturation as determined by pulse oximetry (for example, pulse oximetry at 89% could indicate a need for suctioning).
• Presence of pulmonary secretions.
• Patient showing physical distress signs, such as audible gurgling and restlessness.

However, suctioning simply based on a routine schedule, such as every 2 hours, fails to be an indication for suctioning. Suctioning should be performed based on patient assessment and need rather than on a fixed timetable to prevent unnecessary trauma to the airways.

Hence, the answer is option c